Provide strategic and operational leadership for enterprise-wide complex case management programs serving clinically vulnerable Medicare Advantage members
Drive measurable improvements in quality outcomes, total cost of care, utilization efficiency, member experience, and risk adjustment accuracy
Partner closely with Clinical Operations, Medical Directors, Quality, Risk Adjustment, Network, Analytics, and Vendor Management to design and scale high-impact interventions
Ensure programs align with CMS requirements, MA Star Ratings, HEDIS, CAHPS, and evolving end-of-life best practices
Champion a member
and caregiver-centered approach, improving satisfaction and reducing care fragmentation
Collaborate with Medical Directors and Clinical leaders to ensure appropriate intensity of care, hospice and palliative referrals, and site-of-care optimization
Educate clinical teams on the intersection of complex care, end-of-life care, and risk adjustment accuracy without compromising care integrity
Establish performance standards, KPIs, and outcomes dashboards for complex case management programs
Mentor and develop clinical leaders, fostering a culture of accountability, compassion, and continuous improvement

8+ years of progressive leadership experience in case management, population health, or medical management
Deep experience with Medicare Advantage, including CMS regulations, Stars, HEDIS, and MA quality frameworks
Demonstrated expertise in complex care management, high-risk populations, palliative care, and/or end-of-life care
Strong understanding of utilization management, total cost of care drivers, and value-based care models
Working knowledge of risk adjustment (HCCs) and clinical documentation improvement in MA populations
Proven ability to lead large, distributed clinical teams and influence across matrixed organizations
Master’s degree in Healthcare Administration, Public Health, or related field
Clinical licensure (e.g., RN, NP, MD, DO) preferred
Lean Six Sigma, other processes improvement certification, Certified Professional in Healthcare Quality (CPHQ), or Certified Professional in Healthcare Management (CPHM) preferred

AVP, Care Anywhere – High Risk Case Management

Key skills