WORK ARRANGEMENT: Remote, with occasional travel as needed for meetings, audits, training, or other business requirements.
JOB SUMMARY:Responsible for leading governance, audit readiness, training, policy and procedure management, corrective action oversight, and performance improvement across Physical Health Utilization Management, Behavioral Health Utilization Management, Pharmacy Utilization Management, and Appeals and Grievances.
Reporting to the Chief Medical Officer, the Director provides centralized leadership for internal and delegated entity auditing, continuous regulatory and accreditation readiness, corrective action monitoring, operational training, process standardization, and alignment of policies and procedures across the assigned functions.
Works closely with clinical and operational leaders to translate Medicare Advantage, Marketplace, state, accreditation, contractual, and organizational requirements into consistent and sustainable operational practices. Serves as the Chief Medical Officer's designated leader for governance and performance activities within the assigned areas and provides leadership to audit, training, administrative support, and process improvement staff.
KEY RESPONSIBILITIES:- Lead governance and performance activities across Physical Health UM, Behavioral Health UM, Pharmacy UM, and Appeals and Grievances.
- Maintain continuous readiness for CMS, Marketplace, state, URAC, delegated oversight, contractual, and internal audits.
- Develop and oversee risk-based internal and delegated entity audits, including operational and clinical reviews.
- Establish standardized audit tools, sampling methods, scoring, documentation requirements, reporting, and escalation thresholds.
- Analyze audit and monitoring results to identify trends, control gaps, training needs, repeat findings, and systemic risk.
- Oversee corrective action plans, including root cause analysis, accountable owners, remediation timelines, effectiveness monitoring, and closure.
- Escalate material findings, delayed remediation, repeat deficiencies, and delegate performance concerns to the Chief Medical Officer and appropriate leaders.
- Oversee onboarding, annual, regulatory, remedial, and role-specific training and monitors completion, competency, and effectiveness.
- Lead the development, alignment, implementation, and maintenance of policies, desk level procedures, and related operational documents.
- Monitor regulatory and accreditation changes and coordinates updates to policies, procedures, training, audit tools, and operational practices.
- Use audit findings, appeals and grievance trends, complaints, overturns, delegate performance, and operational data to identify improvement opportunities.
- Lead process improvement initiatives and cross-functional workgroups addressing operational, regulatory, and performance concerns.
- Develop reports and governance updates for the Chief Medical Officer, functional leaders, and applicable committees.
- Partner with Compliance, Legal, Quality, Contracting, Credentialling, HR, and other departments as appropriate.
- Provide leadership, performance oversight, and professional development for assigned audit, training, administrative support, and process improvement staff.
- Perform other related job duties as required or assigned.
QUALIFICATIONS:- Demonstrated leadership ability within a health plan, managed care, or similarly regulated health care environment.
- Strong knowledge of Medicare Advantage and Marketplace regulatory and operational requirements for a health plan.
- Broad understanding of health plan operations, including utilization management, prior authorization, organization and coverage determinations, appeals, grievances, notices, delegation, and member and provider communications.
- Demonstrated experience with continuous audit readiness, internal auditing, delegated entity oversight, corrective action planning, policy and procedure management, training, and performance improvement.
- Ability to interpret complex regulatory, accreditation, contractual, and operational requirements and translate them into practical and sustainable processes.
- Strong analytical skills with the ability to identify trends, systemic risks, control gaps, root causes, and improvement opportunities.
- Ability to exercise authority and influence across multiple operational areas while maintaining collaborative relationships with functional leaders.
- Ability to distinguish regulatory requirements from organizational policy, clinical judgment, and operational preference.
- Well-developed written, verbal, interpersonal, facilitation, and presentation skills.
- Strong organizational and project management skills with the ability to manage competing priorities and regulatory deadlines.
- Ability to respectfully challenge existing practices, escalate concerns appropriately, and facilitate cross-functional resolutions.
- Demonstrated sound judgment, integrity, accountability, professionalism, and discretion.
- Successful completion of Health Care Sanctions background check.
- Successful completion of pre-employment drug testing.
- Ability to converse and write fluently in English.
EDUCATION/EXPERIENCE:- Bachelor's degree in health care administration, business administration, public health, nursing, compliance, pharmacy, quality, or a related field.
- Minimum of five years of progressive experience in health plan operations, utilization management, appeals and grievances, regulatory operations, auditing, accreditation, delegated oversight, performance improvement, or a related function.
- Minimum of three years of leadership or supervisory experience, including responsibility for staff performance, development, and accountability.
- Demonstrated experience supporting or leading CMS, URAC, state, delegated entity, client, or internal audit activities.
- Demonstrated experience developing or overseeing audit programs, corrective action plans, policies, procedures, training programs, or operational monitoring.
- Experience with Medicare Advantage program audits, organization determinations, coverage determinations, appeals, grievances, reopening requirements, and delegated oversight strongly preferred.
- Experience with Marketplace requirements and URAC accreditation audits strongly preferred.
- Experience leading multidisciplinary teams or functions involving audit, training, policy management, administrative support, or process improvement preferred.
- Advanced degree or certification in health care administration, compliance, quality, audit, project management, or process improvement preferred.
