MedStar Southern Maryland Hospital Center

Director Utilization Management MedStar Family Choice

MedStar Southern Maryland Hospital Center • $120K — $238K *
Washington, DC 20011In-Person
Healthcare
8 - 10 years of experience
Reposted 3 days ago
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Job Overview by Ladders

Qualifications

  • Bachelor's degree in Nursing, Social Work, or related healthcare field required.
  • Master's degree in Nursing (MSN), Public Health (MPH), Healthcare Administration (MHA), Business Administration (MBA) or related field preferred.
  • 8-10 years of managed care experience required.
  • Minimum 5 years of utilization management leadership experience required.
  • Experience with centralized operations and Medicaid managed care preferred.
  • Registered Nurse (RN) State Licensure required.

Responsibilities

  • Leads enterprise-wide utilization management strategy across all health plans.
  • Standardizes UM policies and workflows for consistency and scalability.
  • Oversees prior authorization and reviews for timely compliance.
  • Ensures adherence to state Medicaid, NCQA, CMS, and contractual requirements.
  • Partners with medical directors for clinical decision-making and criteria application.
  • Develops performance dashboards to monitor UM metrics.
  • Drives medical expense management initiatives by analyzing utilization trends.

Benefits

  • Opportunity for career advancement within a leading healthcare organization.
  • Engagement in shaping strategic initiatives for improved healthcare outcomes.
  • Collaboration with various departments to enhance service delivery.
  • Focus on quality of care and patient-centered decision-making.
  • Access to a team of skilled professionals in a supportive work environment.
Full Job Description
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.

    About MedStar Southern Maryland Hospital Center

    MedStar Southern Maryland Hospital Center is a medical facility located in Clinton, Maryland. It is a 192-bed acute care hospital that provides a range of services including emergency care, cardiology, cancer care, orthopedics, and women's health. The hospital is part of the MedStar Health system, which is the largest healthcare provider in Maryland and the Washington, D.C. region. MedStar Southern Maryland Hospital Center is committed to providing high-quality, compassionate care to its patients and improving the health of the communities it serves.
    Learn more about MedStar Southern Maryland Hospital Center
    Size
    1,200 employees
    Industry
    Healthcare
    * Ladders Estimates

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