Director of Medical Management

Company: Blue Zones Health
Location: Los Angeles
Posted on: January 13, 2026

Job Description:

Job Description Position Summary The Director of Medical Management will be responsible for leading and overseeing the Blue Zones Health clinical operations, with a primary focus on utilization management, care management, and regulatory audit readiness. This role ensures that medical management programs are compliant, efficient, and aligned with payer and CMS requirements, while supporting high-quality, cost-effective care delivery. The compensation range for this role is $160,000 - $180,000 annually. Key Responsibilities Utilization Management (UM) Oversee all UM functions including prior authorization, concurrent review, post-service review, and appeals. Ensure timely and clinically appropriate decision-making in accordance with regulatory and contractual requirements. Develop and maintain UM policies and procedures aligned with CMS, DHCS, and health plan standards. Monitor denial rates, turnaround times, and inter-rater reliability; implement corrective actions as needed. Collaborate with medical directors and provider groups to ensure alignment with clinical criteria and protocols. Care Management Lead care coordination and case management programs targeting high-risk, high-utilization populations. Assist with overseeing transitions of care, discharge planning, and chronic disease management initiatives. Ensure care management workflows support improved outcomes, reduced avoidable admissions, and member engagement. Supervise clinical staff including RNs, LVNs, and social workers involved in care coordination. Delegation Oversight Manage oversight of delegated entities (e.g., IPAs, vendors) for UM and care management functions. Quality Oversight (Audit-Focused) Lead preparation and response efforts for health plan, CMS, and DHCS audits related to UM and care management. Ensure documentation, workflows, and systems are audit-ready and compliant with regulatory standards. Partner with compliance and legal teams to address findings and implement remediation plans. Maintain current knowledge of regulatory changes and ensure operational alignment. Leadership & Collaboration Build and lead a high-performing medical management team, fostering accountability and continuous improvement. Serve as a clinical liaison between BZH and provider organizations, health plans, and regulatory bodies. Collaborate with IT and analytics teams to ensure accurate reporting and data-driven decision-making. Qualifications RN or equivalent clinical degree required Minimum 7 years of experience in medical management, utilization review, or care coordination. The role requires a comprehensive understanding of utilization management workflows and processes, the ability to navigate existing systems and model best practices, and strong expertise in collecting, analyzing, and interpreting data to drive informed, evidence-based decisions Deep understanding of CMS, DHCS, DMHC, and health plan requirements for UM and care management. Proven experience leading audit preparation and delegation oversight. Strong leadership, communication, and strategic planning skills. Ability to travel as needed For more information about Blue Zones Health , check us out at www.bluezoneshealth.com. Blue Zones Health does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age, disability, veteran status, or any other protected status under applicable law.

Keywords: Blue Zones Health, Huntington Park , Director of Medical Management, Healthcare , Los Angeles, California