Medical Management - Director Utilization Management 145-7002

CommunityCare•Tulsa, OK

About The Position

The Director Utilization Management provides strategic and operational leadership for the health plan’s Physical Health Utilization Management department and reports to the Chief Medical Officer. The Director leads supervisors responsible for a large utilization management team, ensures reliable and compliant daily operations, and develops data-driven strategies to improve clinical appropriateness, affordability, efficiency, accuracy, and quality. The Director oversees prospective, concurrent, and retrospective clinical review; establishes and monitors operating expectations; and leads workforce planning, performance management, succession planning, and leadership development. The role analyzes utilization, cost, quality, provider, and operational data; evaluates the impact of prior authorization and other utilization controls; ensures compliance with benefits, clinical criteria, regulatory requirements, and accreditation standards; and oversees delegated utilization management performance. The Director also evaluates and implements utilization management technology, including automation, AI-assisted tools, and clinical decision support. The role partners across clinical and operational functions and provides leadership and governance bodies with reporting and recommendations on performance, risks, resource needs, and strategic opportunities. Other job-related duties may be assigned.

Requirements

Bachelor of Science in Nursing from an accredited school of nursing.
Current, active, unrestricted Registered Nurse license in Oklahoma, and ability to obtain and maintain any future license required for the position.
At least ten years of progressive clinical nursing, managed care, or health plan clinical operations experience, including at least five years of direct health plan utilization management experience.
At least seven years of progressive management experience, including experience leading a large or multilayered clinical operations function and managing managers, supervisors, or team leads.
Expert knowledge of health plan utilization management operations, benefit administration, medical necessity review, clinical criteria, regulatory requirements, accreditation standards, and delegated oversight.
Ability to analyze utilization, cost, quality, and operational data and translate findings into strategy, execution, and measurable results.
Demonstrated ability to lead complex operations, improve workflows, and maintain accountability for service, quality, compliance, and financial performance.
Proficiency with utilization management platforms, analytics and visualization tools, Microsoft applications, automation, AI-assisted workflows, and other emerging technology.
Strong cross-functional leadership, judgment, communication, organizational, and change-management skills.
Successful completion of a Health Care Sanctions background check.

Nice To Haves

Master’s degree in nursing, health care administration, business administration, public health, informatics, or a related field.
Experience supporting more than one health plan line of business, particularly Medicare Advantage, Commercial, or Marketplace products.
Experience with recognized clinical decision-support criteria, claims and utilization analytics, and delegated utilization management oversight.

Responsibilities

Direct the strategy and daily operations of Physical Health Utilization Management across prospective, concurrent, and retrospective clinical review.
Establish and monitor expectations for workload, staffing, coverage, productivity, quality, documentation, escalation, and turnaround times, and address risks proactively.
Lead Utilization Management supervisors and oversee operational performance, workforce planning, recruitment, performance management, succession planning, and leadership development.
Analyze utilization, cost, quality, provider, and operational data to identify trends and variation, set priorities, and implement measurable strategies to improve appropriate utilization and affordability.
Evaluate the clinical, financial, operational, member, and provider impacts of prior authorization and other utilization controls, and recommend changes based on results.
Ensure consistent application of benefits, approved coverage hierarchy, clinical criteria, policies, and federal, state, and accreditation requirements; maintain operational readiness and timely corrective action.
Partner across clinical and operational functions to resolve issues, reduce rework, and implement sustainable improvements while maintaining accountability for Physical Health Utilization Management.
Evaluate and implement utilization management technology, including automation, AI-assisted tools, and clinical decision support; define operational requirements and work with governance to monitor efficiency, accuracy, quality, and compliance.
Oversee delegated utilization management performance and recommend an operating model based on service, quality, compliance, member impact, and cost.
Provide leadership and governance bodies with reporting and recommendations on performance, risks, resource needs, and strategic opportunities.
Perform other job-related duties as required or assigned.