Director, Utilization Management

COMPANY OVERVIEW At Harbor Health, we’re transforming healthcare in Texas through collaboration and innovation.  We’re seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model.

If you’re ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

POSITION OVERVIEW We are seeking a dynamic and visionary Clinical Nurse Director of Utilization Management to lead the development of our Utilization Management (UM) program in a startup healthcare organization.

This leader will be responsible for designing and building the department , establishing evidence-based standard operating procedures, identifying and addressing staffing and resource needs, overseeing recruitment and team development, and fostering a culture of excellence, accountability, and innovation .

The ideal candidate is an experienced and flexible nurse leader with deep knowledge of utilization management, strong organizational design skills, and the ability to thrive in a fast-paced, evolving environment.

This is a rare opportunity to shape the future of a UM program from the ground up.

The Director provides strategic leadership, operational oversight, and regulatory compliance for all utilization management functions within the organization.

This role is responsible for ensuring appropriate, cost-effective, and quality-driven medical services are provided to members through effective authorization management, clinical review, and adherence to evidence-based guidelines.

The Director leads initiatives to achieve compliance with NCQA (National Committee for Quality Assurance) standards, state and federal regulatory requirements, and health plan policies.

The Director oversees daily operations of prior authorization, concurrent review, retrospective review, appeals, and clinical review processes, while working cross-functionally with providers, care management, quality, and compliance teams to ensure alignment with organizational goals and contractual obligations.   POSITION DUTIES & RESPONSIBILITIES Leadership & Strategy Develop and implement strategic plans for Utilization Management aligned with organizational goals and value-based care initiatives.

Provide leadership, direction, and mentorship to UM managers, supervisors, and clinical / non-clinical staff.

Collaborate with senior leadership to optimize resource allocation, staffing, and operational efficiency.

Serve as a key advisor on UM trends, best practices, and healthcare industry changes impacting authorizations and care delivery.

Utilization Management Operations Direct all UM activities including prior authorization, concurrent review, retrospective review, medical necessity determinations, and appeals .

Ensure clinical decisions are based on evidence-based guidelines, InterQual / MCG criteria, and health plan policy .

Oversee the accuracy and timeliness of service authorizations to meet regulatory and contractual requirements.

Monitor turnaround times, denial rates, and approval processes to ensure high-quality, compliant operations.

Develop and oversee reporting tools to track UM performance metrics, provider trends, and cost of care impact.

NCQA & Regulatory Compliance Ensure UM policies, procedures, and workflows are NCQA-compliant and aligned with accreditation standards.

Lead UM-related NCQA accreditation activities, including preparation, audits, and corrective action plans.

Stay current with state, federal, CMS, Medicaid, and Medicare requirements affecting utilization management.

Partner with Compliance and Quality departments to implement corrective actions when deficiencies are identified.

Clinical & Provider Engagement Collaborate with Medical Directors to review and approve medical necessity determinations.

Work with providers and health systems to improve authorization processes, reduce administrative burden, and strengthen provider relationships.

Facilitate provider education and communication on UM requirements, clinical guidelines, and policy changes.

Data, Reporting & Continuous Improvement Develop dashboards and reporting mechanisms for UM performance, trends, and compliance metrics.

Use data analytics to identify opportunities for process improvement, cost savings, and quality enhancement.

Lead initiatives to reduce unnecessary utilization while ensuring access to medically necessary care.

Support initiatives to integrate UM with Case Management, Disease Management, and Quality programs.   DESIRED PROFESSIONAL SKILLS & EXPERIENCE Education & Experience Bachelor’s degree in Nursing, Healthcare Administration, or related field required.

Master’s degree in Nursing, Healthcare Administration, Public Health, or related field preferred.

Active RN license (or other clinical licensure such as MD, DO, PA, NP) required.

Minimum 8–10 years of progressive experience in utilization management, care management, or medical management within a health plan or managed care organization.

Minimum 5 years in a leadership / management role overseeing UM operations.

Direct experience with NCQA accreditation, survey readiness, and compliance programs required.

Skills & Competencies Strong knowledge of NCQA UM standards, CMS guidelines, state / federal regulations, and health plan operations .

Expertise in prior authorization, concurrent review, retrospective review, and appeals.

Ability to analyze clinical and operational data to drive strategic decisions.

Exceptional leadership, team-building, and staff development skills.

Strong organizational and project management abilities.

Excellent communication and collaboration skills with clinicians, providers, regulators, and internal teams.

Proficiency in UM software platforms, EMRs, and data reporting tools.

Performance Metrics Compliance with NCQA standards and successful survey outcomes.

Timeliness and accuracy of authorizations and determinations.

Reduction in unnecessary utilization and improvement in medical cost management.

Provider and member satisfaction scores related to UM processes.

Staff retention, training completion, and engagement.

Working Conditions Remote with occasional on-site meetings Standard business hours with availability for leadership calls, accreditation activities, and regulatory audits.

Occasional travel for meetings, trainings, or provider engagement.   At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation.

We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model.

If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

Harbor Health is an Equal Opportunity Employer.

We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic protected by law.

We are committed to creating an inclusive environment for all clinicians and teammates and actively encourage applications from people of all backgrounds.

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