Director, Utilization Management

HealthFirst•Herminie, PA

1d•Hybrid

About The Position

The Director of Utilization Management is a transformational clinical operations leader responsible for delivering strategic and operational oversight for Utilization Management (UM) teams. This high-impact forward-thinking leader drives clinical and operational excellence across all UM functions, including prior authorizations, concurrent reviews, and service requests while ensuring the delivery of medically necessary, cost-effective, and high-quality care in full compliance with CMS, NYSDOH, and contractual requirements. The Director will bring deep operations leadership experience, executive presence, strong change management capability, and a modernization mindset with the ability to lead transformation initiatives in complex healthcare environments. This dynamic leader will leverage data-driven decision making to drive process improvement through workflow automation, AI-enabled decision support, and streamlined UM operations that helps shape the future of utilization management.

Requirements

Bachelor’s 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.

Nice To Haves

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

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 Healthfirst’s 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