Medical Management - Director Utilization Management 145-7002

Community Care•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 role directs prospective, concurrent, and retrospective clinical review; establishes and monitors operational expectations; and leads workforce planning and performance. The Director analyzes clinical, financial, provider, and operational outcomes, evaluates utilization controls, and recommends improvements. The position also ensures consistent application of benefits, coverage hierarchies, clinical criteria, policies, and regulatory and accreditation requirements; oversees delegated utilization management performance; evaluates technology and automation; and reports performance, risks, resource needs, and strategic opportunities to leadership and governance bodies.

Requirements

Bachelor of Science in Nursing from an accredited school of nursing.
Current, active, unrestricted Registered Nurse license in Oklahoma, with the ability to obtain and maintain any future license required for the position.
At least 10 years of progressive clinical nursing, managed care, or health plan clinical operations experience, including at least 5 years of direct health plan utilization management experience.
At least 7 years of progressive management experience, including 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 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; address operational risks proactively.
Lead Utilization Management supervisors and maintain accountability for 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 that improve appropriate utilization and affordability.
Evaluate 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 clear 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 clear reporting and recommendations on performance, risks, resource needs, and strategic opportunities.
Perform other job-related duties as required or assigned.