Manager, Medical Director - Transformation Initiatives

Manager, Medical Director - Transformation Initiatives

Location:

This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Alternate locations may be considered.

The Manager, Medical Director will serve as a clinical and strategic advisor to enterprise transformation programs spanning affordability, medical cost management, modernization, and growth initiatives. This role provides medical and clinical leadership to ensure that large-scale technology, operations, and product initiatives align with clinical best practices, regulatory requirements, and the organization's goals of affordability, quality, and innovation.

The Medical Director will work closely with engineering, product, operations, and business leaders to shape transformation strategies, assess clinical and financial impacts, and guide implementation of initiatives that impact providers, members, and clients across the healthcare ecosystem.

How you will make an impact:

Strategic Clinical Leadership

* Provide clinical insight and medical guidance across multiple enterprise transformation initiatives, including:

* Medical Cost Management

* HealthOS and enterprise data platforms

* Real-time Decisioning & Analytics (RDA)

* Cost of Care / Payment Integrity

* Care Management / Utilization Management (CM/UM) Modernization

* Provider Networking & Modernization

* Value-Based Care and Carelon Risk models

* Carelon Research & Data Commercialization

* Client Information Insights and CDIP/Consumer Experience

* Advise on Teradata/SAS migration and retirement, ensuring data modernization supports clinical and operational needs.

* Translate complex clinical and regulatory requirements into actionable technical and operational strategies.

Program & Initiative Support

* Partner with SVRO (Strategic Value Realization Office) and enterprise transformation leaders to assess clinical and medical cost implications of strategic initiatives.

* Evaluate program designs for alignment with quality, safety, and evidence-based clinical practice.

* Guide affordability-focused programs with a balance of cost containment, care quality, and provider/member experience.

Collaboration & Influence

* Collaborate with engineering, analytics, and product teams to ensure platforms such as HealthOS and RDA incorporate clinical intelligence and deliver actionable insights.

* Advise Carelon Research and Data Commercialization teams on ethical and clinically appropriate use of healthcare data.

* Partner with Provider Network leaders to shape modernization strategies that drive value-based outcomes and affordability.

* Serve as a clinical voice in modernization of CM/UM platforms, ensuring alignment with regulatory mandates and member engagement expectations.

Regulatory & Compliance Oversight

* Ensure compliance with clinical, accreditation, and regulatory standards across transformation programs.

* Support interpretation of federal/state mandates and advise on clinical implementation strategies.

Minimum Requirements:

* Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).

* Must possess an active unrestricted medical license to practice medicine or a health profession.

* Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.

* Minimum of 10 years of clinical experience: or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:

* 5+ years of clinical practice experience, with transition into payer, managed care, or healthcare leadership preferred.

* Experience advising medical cost management, utilization management, payment integrity, or provider performance programs preferred.

* Strong understanding of healthcare data systems (claims, EHR, analytics platforms) and payer operations preferred.

* Proven ability to influence cross-functional teams and guide complex, enterprise-level initiatives.

* Prior leadership in a payer, health plan, or healthcare innovation organization preferred.

* Familiarity with enterprise platforms such as Teradata, SAS, or cloud-based data ecosystems.

* Experience in value-based care, population health, and care management program design preferred.

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