About the Job General Summary of Position The Director of Utilization Management (UM) provides strategic and operational leadership for the health plan's centralized utilization management function across both plans. This role ensures appropriate evidence-based utilization of services while maintaining regulatory compliance improving quality outcomes and driving cost-effective delivery. Under a centralized clinical operation model the Director aligns UM process across plans standardizes workflows optimizes technology and integrates closely with Case Management Pharmacy Quality and Provider Relations to support enterprise-wide performance goals.
Primary Duties and Responsibilities Leads enterprise-wide utilization management strategy across all health plans under a centralized clinical operation model. Standardizes UM policies workflows and clinical criteria application to ensure consistency and scalability across markets. Oversees prior authorization concurrent review retrospective review to ensure timely and compliant determinations.
Ensures compliance with state Medicaid NCQA CMS and contractual requirements including turnaround time standards. Partners with medical directors to ensure appropriate clinical decision-making and consistent application of medical necessity criteria. Develops and monitors UM performance dashboards including denial rates overturn rates length of stay and turnaround times.
Drives medical expense management initiatives by identifying utilization trends and implementing targeted interventions. Collaborates with Case Management leadership to ensure seamless transitions between UM and care coordination functions. Partners with pharmacy leadership to align utilization controls on high-cost drugs and specialty therapies.
Oversees hospital utilization management including inpatient admission appropriateness DRG optimization and reduction strategies. Identifies and implements process improvement initiatives to increase operational efficiency and reduce variability. Prepares for a lead regulatory audits accreditation reviews and corrective action plans related to UM functions.
Monitors and ensures compliance with evidence-based clinical criteria tools (e.g. InterQual ASAM) and internal policies. Leads workforce planning and staffing models to ensure appropriate caseload distribution and productivity standards.
Supervises and develops UM managers and supervisors including performance evaluations and professional development. Collaborates with Finance and Actuarial team to analyze utilization trends cost drivers and forecast medical expense impact. Supports value-based payment models and alternative payment initiatives by aligning UM process with performance metrics.
Develops escalation and peer review process to manage complex or high-risk clinical determinations. Ensures culturally competent and member- center decision-making balancing access quality and cost stewardship. Provides executive-level reporting and strategic recommendation to the VP of Clinical Operations and senior leadership Minimal Qualifications Education Bachelor's degree Bachelor's degree in Nursing Social Work or related healthcare field required Master's degree Master's degree in Nursing (MSN) Public Health (MPH) Healthcare Administration (MHA) Business Administration (MBA) or related field preferred Experience 8-10 years years of managed care experience required and 5-7 years Minimum 5 years utilization management leadership required and Experience with centralized operations preferred and Demonstrated experience in Medicaid managed care preferred Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure in MD/DC Upon Hire required Knowledge Skills and Abilities Deep understanding of state Medicaid CMS and NCQA requirements Experience in medical necessity criteria tools (InterQual) Strong data analytics and financial acumen Change management expertise Excellent executive communication skills.
This position has a hiring range of USD $120,702.00 - USD $238,222.00 /Yr.