Position Summary:
The Director of Utilization Management (UM) is responsible for the strategic leadership, operational oversight, and regulatory compliance of the health plan’s Utilization Management programs. This role ensures the delivery of high-quality, cost-effective, and evidence-based care through effective management of prior authorization, concurrent review, retrospective review, care coordination, and appeals functions.
The Director will lead multiple interdisciplinary teams and collaborate cross-functionally to drive performance, member satisfaction, regulatory compliance, and financial stewardship.
Key Responsibilities:
- Strategic LeadershipDevelop and execute the UM strategy aligned with organizational goals and regulatory requirements.
- Lead program enhancements to improve quality outcomes, affordability, and member/provider experience.
- Monitor industry trends and regulatory updates to ensure continuous program improvement.
- Partner with executive leadership to establish departmental KPIs and long-term operational plans.
Operational Oversight
- Oversee multiple UM teams, which may include:
- Prior Authorization
- Concurrent Review
- Retrospective Review
- Appeals & Grievances (clinical component)
- Ensure appropriate staffing models, productivity standards, and performance management processes are in place.
- Drive operational efficiency through workflow optimization, automation, and technology enhancements.
- Oversee vendor relationships supporting UM functions.
Clinical & Regulatory Compliance
- Ensure compliance with federal and state regulations (e.g., CMS, NCQA, URAC), accreditation standards, and internal policies.
- Oversee development and maintenance of UM policies, clinical criteria, and decision-support tools.
- Ensure timely and appropriate medical necessity determinations consistent with evidence-based guidelines.
- Support audit readiness and lead corrective action planning when needed.
- Quality & Performance ManagementMonitor UM metrics including turnaround times, denial rates, appeal overturn rates, provider abrasion, and member satisfaction.
- Analyze utilization trends and identify opportunities to improve quality and reduce unnecessary costs.
- Collaborate with Quality, Medical Management, Network, and Finance teams to align initiatives.
- Lead root cause analysis and performance improvement initiatives.
Leadership & Talent Development
- Direct, mentor, and develop managers and supervisors across multiple UM teams.
- Foster a culture of accountability, collaboration, and continuous improvement.
- Promote interdisciplinary teamwork between nurses, physicians, pharmacists, and operational staff.
- Lead change management initiatives across the department.
Qualifications:
- Registered Nurse (RN) required; Bachelor’s degree required.
- Master’s degree in Nursing, Healthcare Administration, Business Administration, or related field preferred.
- 8–10+ years of progressive leadership experience in Utilization Management within a managed care or health plan environment.
- Strong knowledge of physician review services, utilization management, and managed care principles.
- Experience leading multiple teams and managers in a matrixed organization.
- Strong knowledge of CMS, state Medicaid/Medicare regulations, NCQA, and URAC standards.
- Demonstrated success in operational improvement and performance management.
- Deep understanding of medical necessity criteria (e.g., InterQual, MCG).
- Strong analytical and financial acumen.
- Excellent leadership, communication, and change management skills.
- Ability to influence cross-functional stakeholders and executive leadership.
- Experience with UM platforms and data analytics tools.
- Proven ability to manage client relationships and drive operational efficiency in a healthcare setting.
- Experience in workforce planning, scheduling optimization, and resource allocation.
- Track record of implementing process improvements and automation solutions.
- Strong analytical, problem-solving, and leadership skills.
- Excellent communication and interpersonal skills
- Experience with quality assurance
- Ability to thrive in a fast-paced, dynamic healthcare environment.
Location: Remote with occasional travel as needed.
