Manager, Clinical Performance & Cost Optimization

We are seeking a strategic professional to serve as the Manager of Clinical Performance and Cost Optimization. This role is responsible for overseeing and advancing Managed Care Initiatives (MCI) and Medical Expense (MedEx) optimization efforts across our health plans.

The successful candidate will be skilled at interpreting dashboards and clinical data insights to identify cost optimization opportunities, support clinical performance enhancement projects, and inform business units on areas for improvement-all while ensuring alignment with financial and quality objectives.

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Monitors cost and utilization trends daily, identifying opportunities for clinical program enhancement and cost containment.
• Works cross-functionally with internal and external partners (e.g., Utilization Management, Care Management, Actuarial, Health Economics, IT, Claims, Risk Adjustment, and Provider Network) to ensure initiatives drive measurable financial and clinical improvements.
• Serves as key contact for MCI/MedEx initiatives, ensuring effective execution, coordination, and visibility across teams.
• Analyzes and sizes clinical cost optimization opportunities at least annually, ensuring financial feasibility and alignment with clinical objectives.
• Supports the adoption of evidence-based clinical interventions to improve quality while optimizing costs.
• Partners closely with analytics and finance teams (Actuarial, Health Economics, Business Intelligence & Analytics) to develop and refine cost-management metrics and assess initiative impact.
• Interprets and acts on cost trend reports, proactively identifying outliers, flagging high-risk members, and working with clinical teams to optimize interventions.
• Supports and drives initiatives that enhance efficiency, reduce medical costs, and improve care coordination.
• Prepares executive-level reports and presentations, translating complex cost trends into actionable insights for leadership.
• Monitors provider cost and quality performance, ensuring contract alignment and performance accountability.
• Defines, tracks, and refines OKRs for MedEx and MCI initiatives, ensuring measurable impact.
• Partners with clinical teams to design and evaluate programs aimed at reducing avoidable admissions, readmissions, and unnecessary utilization.
• Performs all duties inherent in a managerial role, including hiring, training, developing, recommending salary actions and when necessary, terminating staff.
• Participates in special projects and performs other duties as assigned.

Education:

• Bachelor's Degree in healthcare administration, business, finance, public health, or a related field required
• Master's Degree in healthcare administration, business, finance, public health, or a related field preferred

Work Experience:

• Minimum of five years of experience in healthcare operations required
• Data-driven mindset with strong analytical skills, experience in cost analysis, and a passion for making data-informed decisions required
• Excellent stakeholder management and ability to communicate complex data insights to diverse audiences required
• Ability to work across clinical, financial, and operational teams to execute and measure cost-containment strategies required
• Experience with Medicare and Medicaid operations, risk adjustment, claims, and value-based care models preferred
• Data-driven mindset to continuously monitor cost trends, analyze financial and utilization patterns, develop insights, and support decision-making to ensure initiatives are impactful and aligned with organizational goals required
• Highly analytical, comfortable working with data, and experienced in collaborating with clinical, financial, and operational teams required