Director, Utilization Review

Long Tail Health Solutions

1d•Hybrid

About The Position

Day-to-day operational leadership, staff management, workflow execution, and client delivery. The Director, Utilization Management Operations, is responsible for the daily management and operational execution of Utilization Management services. Reporting to the Senior Director, this role oversees frontline operational teams, managers, and workflows to ensure timely, compliant, and high-quality service delivery for clients. The Director serves as the primary operational leader responsible for workforce management, staff performance, operational consistency, and implementation of organizational standards and processes.

Requirements

Bachelor’s degree in nursing, healthcare administration, or related field.
5+ years of experience in Utilization Review or Case Management
2+ years in a leadership role overseeing clinical teams.
Strong operational management, workflow optimization, and staff development experience.
Extensive knowledge of Utilization Review operations, payer guidelines, and healthcare regulations.
Familiarity with healthcare systems, hospital operations, and revenue cycle functions.
Expertise in process improvement methodologies and project management principles.
Strong communication skills and the ability to speak clearly and persuasively in positive or negative situations, demonstrate group presentation skills, and conduct productive internal and external meetings.
Advanced analytical skills and ability to synthesize complex or diverse information to make strategic decisions quickly and with confidence.
Advanced problem-solving skills to help identify and resolve problems, be they personnel, process, or other, in a timely manner.
Advanced delegation skills and demonstrated ability to prioritize work assignments, give authority to work independently, set expectations, and monitor delegated activities.
Strong leadership skills which inspire and motivate others to perform well while accepting feedback and adapting to the needs of individual team members.
Strong management skills to engage team members in planning, decision-making, facilitation, and process improvement; be available to staff; provide regular performance feedback; and develop subordinates’ skills and encourage growth.
Good judgment, demonstrated by a willingness to gather evidence and diverse viewpoints culminating in making timely decisions which prove to be sound over time.
Quality management skills leveraged to improve and promote quality throughout the organization; demonstrate accuracy and thoroughness; and maintain compliance with legal and regulatory aspects.
Planning and Organization skills supporting the prioritization and planning of work activities, using time efficiently, and developing realistic action plans.
Safety and Security skills to observe, model, and enforce safety and security procedures and proper us of equipment and technology.

Nice To Haves

Master’s degree in business or healthcare administration.

Responsibilities

Manage frontline managers, supervisors, utilization nurses, coordinators, and support staff.
Provide coaching, mentorship, and performance management to operational staff.
Support recruitment, onboarding, workforce planning, and retention efforts.
Serve as primary operational contact for assigned client engagements.
Ensure client deliverables, service expectations, and operational standards are consistently achieved.
Escalate strategic or high-risk concerns to Senior Director leadership.
Ensure adherence to payer guidelines, regulatory standards, and internal operational policies.
Support audit readiness, quality monitoring, and operational compliance initiatives.
Partner with education and quality teams to identify operational improvement opportunities.
Lead recruitment, onboarding, and workforce planning efforts to build and maintain a high-performing team aligned with operational and organizational goals.
Develop staff through coaching, mentorship, performance management, education, and leadership development initiatives that support professional growth and operational excellence.
Foster a culture of accountability, collaboration, engagement, and retention through proactive team support, recognition, and continuous performance improvement.
Oversee daily Utilization Management operations, workflows, and case management activities.
Ensure operational efficiency, productivity, timeliness, and quality performance across assigned teams.
Monitor operational KPIs and implement corrective actions as needed.
Implement standardized workflows, operational tools, and process improvement initiatives.
Utilize data and reporting to drive operational decision-making and performance improvement.
Support implementation of new clients, workflows, and operational enhancements.
Build and maintain strong client relationships through consistent communication, responsiveness, and proactive operational support.
Partner with clients to understand organizational goals, address challenges, and drive high levels of service satisfaction and performance outcomes.
Foster long-term partnerships by delivering operational excellence, identifying opportunities for improvement, and supporting strategic client initiatives.
Ensure operational compliance with applicable regulatory requirements, payer guidelines, contractual obligations, and organizational policies.
Monitor workflows and team performance to identify compliance risks, support audit readiness, and implement corrective actions when necessary.
Provide guidance, education, and oversight to promote accurate, compliant, and consistent utilization management and documentation practices.