JOB SUMMARY:The Director Utilization Management provides strategic and operational leadership for the health plan's Physical Health Utilization Management department and reports to the Chief Medical Officer.
The Director leads supervisors responsible for a large utilization management team; ensures reliable, compliant daily operations; and develops data-driven strategies to improve clinical appropriateness, affordability, efficiency, accuracy, and quality.
KEY RESPONSIBILITIES:- Direct the strategy and daily operations of Physical Health Utilization Management across prospective, concurrent, and retrospective clinical review.
- Establish and monitor expectations for workload, staffing, coverage, productivity, quality, documentation, escalation, and turnaround times; address risks before they affect members, providers, or compliance.
- Provide leadership and direction to Utilization Management supervisors, with accountability for operational performance, workforce planning, recruitment, performance management, succession planning, and leadership development.
- Analyze utilization, cost, quality, provider, and operational data to identify trends and variation, establish priorities, and implement measurable strategies that improve appropriate utilization and affordability.
- Evaluate clinical, financial, operational, and member or provider impact of prior authorization and other utilization controls; recommend changes based on results.
- Ensure consistent application of benefits, approved coverage hierarchy, clinical criteria, policies, and federal, state, and accreditation requirements; maintain operational readiness and timely corrective action.
- Partner effectively across clinical and operational functions to resolve issues, reduce rework, and implement sustainable improvements while maintaining clear accountability for Physical Health Utilization Management.
- Evaluate and implement utilization management technology, including automation, AI-assisted tools, and clinical decision support; define operational requirements and work with governance to monitor results for efficiency, accuracy, quality, and compliance.
- Oversee delegated utilization management performance and recommend the most effective operating model based on service, quality, compliance, member impact, and cost.
- Provide leadership and governance bodies with clear reporting and recommendations on performance, risks, resource needs, and strategic opportunities.
- Perform other job-related duties as required or assigned.
QUALIFICATIONS:- Expert knowledge of health plan utilization management operations, benefit administration, medical necessity review, clinical criteria, regulatory requirements, accreditation standards, and delegated oversight.
- Ability to analyze utilization, cost, quality, and operational data and translate findings into strategy, execution, and measurable results.
- Demonstrated ability to lead complex operations, improve workflows, and maintain accountability for service, quality, compliance, and financial performance.
- Proficiency with utilization management platforms, analytics and visualization tools, Microsoft applications, automation, AI-assisted workflows, and other emerging technology.
- Strong cross-functional leadership, judgment, communication, organizational, and change-management skills.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:- Bachelor of Science in Nursing from an accredited school of nursing required.
- Master's degree in nursing, health care administration, business administration, public health, informatics, or a related field preferred.
- Current, active, unrestricted Registered Nurse license in the state of Oklahoma; ability to obtain and maintain any future license required for the position.
- A minimum of ten years of progressive clinical nursing, managed care, or health plan clinical operations experience, including at least five years of direct health plan utilization management experience.
- A minimum of seven years of progressive management experience, including demonstrated experience leading a large or multilayered clinical operations function and managing managers, supervisors, or team leads.
- Experience supporting more than one health plan line of business, particularly Medicare Advantage, Commercial, or Marketplace products, strongly preferred.
- Experience with recognized clinical decision-support criteria, claims and utilization analytics, and delegated utilization management oversight preferred.
