Director, Utilization Management

Duly Health and Care • Downers Grove, IL

10h • Onsite

About The Position

The Director of Utilization Management (UM) is responsible for the strategic and operational oversight of all delegated UM functions across Duly Health and Care. In this role, Duly operates under delegated authority from health plans, maintaining full accountability for utilization management performance, regulatory compliance, and clinical quality. The Director ensures that all UM activities—including prior authorization, medical necessity review, and care coordination—are executed in alignment with payer requirements, CMS and NCQA standards, and Duly’s clinical and operational priorities. This leader bridges internal operations, payer relationships, and delegated vendors to ensure high-quality, cost-effective care delivery while minimizing regulatory and operational risk.

Requirements

• Active Registered Nurse (RN) license preferred; advanced degree (MSN, MHA, MPH) preferred
• 7–10+ years of experience in utilization management, including leadership experience with a strong operational bakground
• Direct experience with delegated UM models and payer-provider relationships strongly preferred
• Deep knowledge of CMS, NCQA, and other regulatory/accreditation standards
• Experience managing prior authorization, concurrent review, and case management programs
• Strong analytical skills with the ability to translate data into actionable insights
• Proven leadership experience managing teams and complex operations
• Excellent communication and stakeholder management skills

Nice To Haves

• Certified Professional in Utilization Review (CPUR)
• Certified Case Manager (CCM)

Responsibilities

• Oversee all utilization management activities performed under payer delegation agreements
• Ensure end-to-end accountability for UM performance, including timeliness, accuracy, and compliance
• Monitor delegated vendors and internal UM teams executing prior authorizations, concurrent review, and discharge planning
• Ensure adherence to all federal, state, and payer-specific requirements (e.g., CMS, NCQA, URAC)
• Maintain audit readiness for delegated UM functions, including documentation, policies, and workflows
• Lead response efforts for audits, corrective action plans, and regulatory inquiries
• Standardize UM policies, clinical criteria, and workflows across delegated functions
• Ensure alignment between payer requirements and Duly’s internal clinical programs
• Partner with medical directors to ensure evidence-based, consistent decision-making
• Familiar with MCG Guidelines
• Define, monitor, and report on key performance indicators (KPIs), including turnaround times, denial rates, and provider abrasion
• Identify trends and implement continuous improvement initiatives to optimize performance
• Develop executive-level reporting for internal leadership and payer partners
• Serve as the primary liaison between Duly, payer partners, and vendors
• Lead regular operating reviews with health plans to ensure alignment and performance transparency
• Escalate and resolve operational, clinical, or compliance issues
• Lead and develop UM leadership and operational teams
• Foster a high-performance culture focused on efficiency, quality, and accountability
• Provide coaching and guidance to ensure consistent application of UM policies and clinical criteria
• Identify risks related to delegation (e.g., compliance gaps, operational inefficiencies, provider dissatisfaction)
• Implement standardized workflows, automation, and data integration strategies to improve visibility and control
• Drive initiatives to reduce unnecessary utilization while maintaining high-quality patient outcomes

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

What This Job Offers

• Job Type: Full-time
• Career Level: Director