Job Description

Medicare Clinical Lead interfaces with Health Plan leadership team and cross functional business partner to provide expertise in driving quality performance, compliance with Medicare regulations, and program evaluation for utilization management and care management with reporting to appropriate regulatory bodies and health plan leadership.


Primary Responsibilities:

  • Provide clinical support to Utilization management and Appeal/Disputes teams consistent with Medicare Guidelines to meet regulatory and accreditation requirements in addition to performance standard.
  • Perform case reviews with guidance to teams in accordance with process and medical policy updates to ensure accuracy in application of criteria.
  • Participate in code configuration and updating prior authorization lists based on regulatory requirements. Support implementation of clinical policies, programs, and quality initiatives consistent with Medicare policies and statutes.
  • Ensure processes, policies, and audit functions in clinical operations are consistent with the most up to date Medicare and accreditation requirements to drive health plan performance. Closely partners with Compliance and Quality teams to prepare for audits, organize documents, universe data pulls, etc.
  • Support the build of new Medicare lines of business.
  • Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision and values of the organization. Additional tasked assigned as appropriate.

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.


Equal Opportunity Employer Minorities/Women/Veterans/Disabled



  • Bachelor's degree required
  • Arizona licensed LPN, RN or PA required
  • Seven (7) years in health care quality focused roles
  • Significant experience analytic functions, quality assessment, HEDIS measurement, use of claims data, medical record review and clear advancement in responsibilities and outputs is preferred
  • Position must be located in Arizona.
  • Strong analytic skills and the ability to translate data into useable information.
  • Demonstrated organizational and project management skills
  • Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problem
  • Excellent verbal and written communication skills

Application Instructions

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