Job Description:The Director, Utilization Management (UM) is responsible for the strategic leadership, oversight, and operational performance of the Utilization Management department. This role ensures appropriate utilization of healthcare services through effective management of prior authorization, concurrent review, retrospective review, transition of care, and medical necessity determinations. The Director partners closely with clinical, operational, provider, and regulatory stakeholders to improve quality outcomes, manage healthcare costs, and ensure compliance with federal, state, accreditation, and contractual requirements.
The Director leads teams responsible for utilization review activities and drives continuous improvement initiatives focused on efficiency, regulatory compliance, member experience, provider satisfaction, and population health outcomes.
Essential DutiesLeadership & Strategy- Develop and execute Utilization Management strategies that align with organizational goals and regulatory requirements.
- Provide leadership, coaching, and performance management for UM managers, supervisors, nurses, and support staff.
- Establish departmental goals, KPIs, and operational metrics to ensure high-quality performance.
- Foster a culture of accountability, collaboration, innovation, and continuous improvement.
- Partner with executive leadership to identify opportunities for program enhancements and operational efficiencies.
Clinical Operations- Oversee prior authorization, concurrent review, retrospective review, and appeals support processes.
- Ensure timely and accurate medical necessity determinations according to established criteria and guidelines.
- Monitor utilization trends and implement interventions to improve clinical and financial outcomes.
- Collaborate with Medical Directors regarding complex cases and utilization management decisions.
- Ensure effective management of high-risk and high-cost cases requiring enhanced review and coordination.
Regulatory & Compliance- Ensure compliance with CMS, NCQA, URAC, State Medicaid, Medicare, Commercial, and Marketplace requirements as applicable.
- Maintain department readiness for audits, accreditation reviews, and regulatory inspections.
- Develop and update UM policies, procedures, and workflows to meet evolving regulatory standards.
- Monitor compliance metrics and implement corrective action plans when necessary.
Quality & Performance Improvement- Analyze UM performance indicators, including turnaround times, denial rates, approval rates, inpatient utilization, readmissions, and length of stay.
- Develop action plans to address performance gaps and improve outcomes.
- Lead quality improvement initiatives focused on member care, operational effectiveness, and cost management.
- Produce and present reports, dashboards, and recommendations to senior leadership.
Provider & Cross-Functional Collaboration- Establish collaborative relationships with providers, health systems, and community partners.
- Work closely with Care Management, Quality, Provider Relations, Compliance, Pharmacy, and Population Health teams.
- Participate in provider education efforts related to utilization management processes and requirements.
- Support initiatives that improve provider engagement and member experience.
Financial Stewardship- Assist in developing and managing departmental budgets.
- Monitor utilization trends and healthcare expenditures.
- Identify opportunities to reduce unnecessary utilization while maintaining quality and access to care.
- Support organizational medical cost management strategies.
Education- Bachelor's degree in Nursing or a related healthcare field required.
- Master's degree in Nursing, Healthcare Administration, Public Health, Business Administration, or related field preferred.
Licensure & Certifications- Current unrestricted Registered Nurse (RN) license required.
- CCM, ACM, CPHQ, or other relevant healthcare certification preferred.
Experience- Minimum of 7 years of progressive healthcare leadership experience.
- Minimum of 5 years of Utilization Management leadership experience within a health plan, managed care organization, IPA, ACO, or healthcare system.
- Experience with Medicare, Medicaid, and/or Commercial health plan operations preferred.
- Experience managing multi-site or remote teams strongly preferred.
- Demonstrated success leading regulatory audits and accreditation activities.
Knowledge- Extensive knowledge of utilization management principles, medical necessity criteria, and healthcare delivery systems.
- Strong knowledge of CMS, NCQA, URAC, Medicare, Medicaid, and state regulatory requirements.
- Exceptional leadership, organizational, and decision-making skills.
- Strong analytical and data interpretation capabilities.
- Experience using UM platforms, case management systems, and electronic health records.
- Excellent verbal, written, and presentation communication skills.
- Ability to manage multiple priorities in a fast-paced environment.
- Strong relationship-building and stakeholder management skills.
Skills & AbilitiesKey Performance Indicators (KPIs)- Prior authorization turnaround times
- Regulatory and accreditation compliance scores
- Inpatient utilization and length-of-stay metrics
- Readmission rates
- Denial and overturn rates
- Staff engagement and retention
- Provider satisfaction metrics
- Medical cost management outcomes
- Audit readiness and performance
