Director of Utilization Management
Director of Utilization Management
A healthcare organization is seeking an experienced Director of Utilization Management (UM) to provide strategic and operational leadership within its clinical operations division. This role is designed for a seasoned nurse leader who excels in regulatory compliance, operational efficiency, and guiding high‑performing teams.
Position Overview
The Director of UM will oversee all utilization management functions, including authorizations, medical necessity reviews, concurrent and retrospective reviews, and appeals. This leader ensures adherence to regulatory and accreditation standards while enhancing clinical appropriateness, workflow efficiency, and overall member and provider satisfaction.
The role includes leadership of UM supervisors and clinical staff, collaboration across internal departments, and oversight of delegated UM vendors.
Key Responsibilities
- Lead, mentor, and evaluate UM supervisors and clinical staff, promoting accountability and professional growth.
- Oversee daily UM operations, ensuring alignment with evidence‑based criteria and all regulatory requirements.
- Ensure compliance with accreditation and state/federal standards through documentation oversight, audit readiness, and process improvement.
- Manage delegated UM vendor relationships, including performance reviews, compliance monitoring, and corrective action plans.
- Analyze UM data to identify trends, inform operational strategies, and support organizational objectives.
- Collaborate with internal partners to improve care quality, manage utilization appropriately, and support continuity of care.
Supervisory Scope
- Direct leadership of UM supervisors and clinical staff.
- Oversight of delegated vendor teams in partnership with vendor leadership.
Required Qualifications
- Minimum of five years of utilization management experience within managed healthcare.
- Prior supervisory or management experience in a UM setting.
- Strong understanding of regulatory and accreditation requirements relevant to UM.
- Advanced proficiency in Excel and data analysis.
- Excellent communication and leadership skills.
Ideal Candidate Profile
Successful candidates will bring:
- In‑depth knowledge of clinical criteria and accreditation standards.
- Experience leading UM programs through audits and ongoing compliance readiness.
- Proven success in vendor oversight and performance management.
- A data‑driven approach to improving turnaround times, appeals outcomes, and operational efficiency.
- A collaborative and influential leadership style that aligns UM goals with broader organizational
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