Director, Utilization Management
- Full-time
Clinical Nurse Director Of Utilization Management
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!
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
- Utilization Management Operations
- NCQA & Regulatory Compliance
- Clinical & Provider Engagement
- Data, Reporting & Continuous Improvement
Desired Professional Skills & Experience
Education & Experience
Skills & Competencies
Performance Metrics
Working Conditions
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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