Director Utilization Management

Job Title

Duties / / Responsibilities :

Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests.

Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching.

Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements.

Deliver on Healthfirsts Mission by ensuring optimum quality of member care in a cost-effective manner.

Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department Of Health (DOH), and other oversight entities.

Develop and monitor appropriate metrics to maintain and improve department performance.

Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement.

Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology.

Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives.

Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions.

Partner with technology and data teams to refine data governance and reporting, inform AI use cases, and performance monitoring frameworks.

Support organizational change management for UM modernization efforts, fostering engagement, communication, and adoption of new technologies or processes.

Advocate and actively participate as the clinical voice on various clinical committees and other clinical policy workgroups.

Additional duties as assigned.

Minimum Qualifications :

Bachelors degree in healthcare, business, or a related field from an accredited institution or equivalent work experience.

Progressive leadership experience in healthcare management including work experience in a mid-senior management role.

Work experience and deep familiarity of health plans such as Medicare, Medicaid and / / or Managed Long-Term Care Plan (MLTCP).

Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations.

Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS.

Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions.

Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.

Preferred Qualifications :

Masters degree in health-related area.

Proven ability to lead complex teams and manage interdisciplinary care models in a health plan or integrated delivery system.

Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.

Strategic thinker with strong operational discipline and capacity for executive-level decision-making.

Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC.

Strong computer skills, including, but not limited to word processing, spreadsheets, and databases.

Compliance & Regulatory Responsibilities : Noted Above.

License / / Certification : N / / A.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State / Province or Local status unrelated to the performance of the work involved.