Job Description

Job Title: AVP Medicaid Clinical Operations
Job ID: 680135
Status: Full-Time
Regular/Temporary: Management
Shift: Day Job
Facility: UPMC Health Plan
Department: Medical Mgmt Admin
Location: 600 Grant St, Pittsburgh PA 15219


The AVP will have the exciting opportunity to join a growing and diversifying integrated delivery and financing system as a clinical leader in the transformation to a population health management care and operating model for the Medicaid Product Line of the UPMC Insurance Division. He/she will serve as a change agent in the way UPMC Health Plan manages all clinical operating aspects of Medicaid and serve as a member of the team leading the transformation to a population health service delivery model that addresses health access and other important matters of Medicaid Members.


As an integral part of the organization, it is paramount that this role exhibits leadership qualities and expertise that will raise UPMC Health Plan to new levels of excellence and execution for underserved and deprived member populations. The success of UPMC Health Plan will rely upon this individual's creativity, discipline, detail and a passion to 'make a real difference' beyond conventional managed care. The AVP Medicaid Clinical Operations reports to the SVP Population Health and Chief Clinical Administrative Officer.


  • Creates clinical archetypes based on population profiles of health status, health risks, health engagement activities and outcomes building expertise in the clinical trends of member populations.
  • Designs and recommends new chronic condition care management pathways that structure longitudinal care over time with holistic quality and cost measures.
  • Establishes new and enhance care management models of care associated with complex members requiring higher levels of coordination and management of chronic and acute care clinical services.
  • Establishes, in collaboration with the Quality Department, the advancement of population health oriented, medical standards and member outcome measures that inform improvement opportunities and guide the formation of more responsive network models for managing chronic conditions/disease and promoting health.
  • Leads innovative medical/clinical programs through early ideation, development and early implementation.
  • Oversees the progressive improvement and overall management of the combined utilization and care management of special needs children.
  • Participates in research and educational activities that promote new knowledge development and action in the clinical field that promotes the effective transformation to a population health management model.
  • Recommends medical policies that promote the transformation from conventional payer-provider services towards both individual and population based improvements in medical outcomes over time.
  • Responsible for coordinating clinical responses for Medicaid Requests for Proposals.
  • Responsible for meeting clinical Medicaid UPMC strategic goals and initiatives. Responsible for implementing programs and strategies to meet strategic goals, identifies barriers, escalated issues to executive management and reports at least annually accomplishments related to strategic goals
  • Responsible for oversight of the Special Needs Coordinator (SNU Coordinator) and the related PRC initiatives.
  • Serves as a clinical administrative, executive liaison with the Department of Health and Human Services. Participates and leads the quality review and improvement meetings (QQRM). Works with product line leaders to orchestrate strategies targeted to enhance member services and strengthen regulatory compliance.
  • Serves as a community leader and positive professional influence in the knowledge development, communication and change process towards an accountable community that promotes health.
  • Works with advanced practice nurses to establish prescribing protocols and medical management strategies with member populations in the home and community based environment.
  • Works with health plan leaders in clinical operations to improve the performance and utility of non-physician, clinical services impacting gaps in care closure, transition of care outcomes and longitudinal management of high risk members.
  • Works with physician and administrative leaders within the network and product line to assess health disparities and related socioeconomic factors impacting members and prospective members. Studies health disparities; identifies goals to reduce health disparities and establishes health plan related strategies to positively impact them.
  • Works with the network leaders to evaluate performance of value based payment arrangements; serves as a mentor to network physician members in the performance improvement and transformation to a high performing provider network and managing populations at risk.


  • Bachelors and Masters Degree required in health care or related field.
  • Minimum of five or more years of proven experience and innovation managing the health needs of Medicaid or like insurance products or state based services and a demonstrated passion for enhancing the access, quality and cost of health services for Medicaid populations.
  • Experience in Medicaid healthcare insurance, State Medicaid or related organizations; ideally having created and driven innovative clinical program initiatives.
  • Health insurance industry experience preferred within a health plan, an integrated delivery and financing system that has truly developed a relationship with the physician and patient community; genuinely collaborative in nature, value-added versus commodity-driven, cross-functionally efficient and consumer-driven.
  • Will possess a passion and commitment to help change the way healthcare is delivered, a track record of developing leading-edge Health Plan clinical strategies while motivating an organization to achieve stretch goals to drive innovation, and do what is right today, rather than tomorrow.
  • Ability to lead, motivate and mentor superior staff in pursuit of progressive programming.
  • Solicit support, evaluate, direct and hold ones self and employees accountable, while maintaining high morale and productivity during favorable and unfavorable conditions.
  • Expert managed care clinical leadership skills, leveraging a broad knowledge base in managed care.
  • Must possess a global understanding of the industry and Medicaid policy and services: legislative/regulatory developments, national product and delivery trends, maintenance of key industry relationships and tracking competitors.
  • Highly developed interpersonal and communication skills, both written and verbal, and an executive demeanor which interacts effectively with all organizational stakeholders regarding sensitive and/or complex topics.
  • Will need to manage multiple tasks and projects, and forge strong interpersonal relationships within the department, with other departments and with external audiences.
  • Must achieve results ahead of schedule and within budget.
  • Highly developed analytical skills.
  • Operates effectively in a matrix environment.
  • Views the various matrix partners within UPMC as customers.
  • Possesses the appropriate level of patience, and persistence, to move issues forward while competing in a highly complex, turbulent, and market-driven industry.
  • Ability to work in a fast-paced environment required.
  • Must demonstrate a high degree of professionalism, enthusiasm and initiative on a daily basis.
  • Exudes a leadership style emphasizing collaboration, teamwork, participation and communication.
  • Willingness and ability to delegate responsibility to senior subordinates while allowing them room to identify ways and means to take action and accomplish specific goals and objectives.
  • Contributes imaginative and innovative ideas; encourages idea generation of others; open, accessible and communicative

    Licensure, Certifications, and Clearances:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $0 to $0

Union Position: No

Apply Current Employee?


At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.


Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

UPMC Ranked #17 Best Places for Women & Diverse Managers in 2018

Talent Network