Director of Utilization Management

Accountabilities: The Director of Utilization Management will lead the strategy, operations, and continuous improvement of utilization management programs while ensuring compliance, quality, and scalability. Key responsibilities include:

Lead and manage clinical and non-clinical utilization management teams to ensure timely, accurate, and consistent review of prior authorizations and appeals.

Develop, maintain, and oversee utilization review plans, policies, procedures, workflows, and operational standards.

Partner with medical leadership to establish and review medical necessity criteria, benefit guidelines, and utilization management decision-making processes.

Drive quality improvement initiatives, including audits, performance evaluations, consistency reviews, and annual inter-rater reliability testing.

Ensure utilization management programs align with contractual requirements, regulatory standards, accreditation expectations, and client objectives.

Maintain and execute workplans supporting NCQA certification and other applicable quality requirements.

Collaborate with executive leadership and cross-functional teams to align utilization management strategies with broader organizational goals.

Support client-facing activities, including business reviews, program consultations, and growth initiatives.

Oversee utilization management technology platforms, system configurations, and operational improvements to enhance efficiency.

Develop staffing models and resource plans that support business growth and evolving operational needs.

Establish performance goals, monitor team results, and foster a culture focused on accountability, collaboration, and continuous improvement.

Manage relationships with internal stakeholders, external partners, and healthcare organizations to ensure effective program delivery.

Requirements:

The ideal candidate should have extensive experience in utilization management, managed care operations, and healthcare leadership. Required qualifications include:

Bachelor’s degree in a relevant field preferred.

Minimum of 10 years of utilization management leadership experience within a managed care environment.

Proven experience managing clinical and non-clinical healthcare teams.

Experience with utilization management accreditation standards, including NCQA or URAC certification requirements.

Strong clinical knowledge and analytical skills with the ability to evaluate medical records, identify trends, and develop improvement strategies.

Experience developing healthcare policies, procedures, workflows, and operational frameworks.

Ability to manage complex healthcare programs while ensuring compliance with legal, regulatory, and quality standards.

Strong understanding of utilization review processes, medical necessity criteria, and healthcare benefit management.

Excellent verbal and written communication skills with the ability to collaborate across all levels of an organization.

Strong interpersonal skills and the ability to build effective relationships with clients, executives, and healthcare professionals.

Proven ability to lead teams, manage change, and drive operational excellence in a growing environment.

Benefits:

Competitive annual compensation of $160,000.

Annual bonus program opportunities.

Remote work flexibility.

Medical, dental, and vision insurance coverage.

401(k) retirement plan with company match.

Company-paid life insurance.

Company-paid short-term disability coverage where applicable.

Paid time off (PTO), sick time, and company holidays.

Paid parental leave.

Quarterly company-sponsored events.

Health and wellness programs.

Career development and growth opportunities.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether? 

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