National Director of Managed Care

ClearSky Health • Albuquerque, NM

1d

About The Position

The National Director of Managed Care provides strategic leadership for managed care operations across the organization. The role drives patient access, referral growth, and revenue performance by developing payer partnerships, optimizing prior authorization processes, and strengthening collaboration among health plans, physicians, and hospital teams. The Director works closely with payer medical directors and clinical admissions teams to reduce barriers to admission, improve authorization outcomes, minimize denials, and support timely transitions of appropriate patients into inpatient rehabilitation.

Requirements

• Bachelor’s degree in healthcare administration, business administration, nursing, or a related field; direct experience in healthcare leadership may be substituted for education on a year-for-year basis.
• Five years of progressive leadership experience in healthcare managed care, utilization review, or payer relations.
• Advanced knowledge of Medicare Advantage (Part C) utilization management structures, clinical guidelines, and prior authorization regulations.
• Comprehensive knowledge of post-acute operational models and CMS medical necessity requirements.
• Knowledge of payer types in the healthcare industry.
• Demonstrated effectiveness in conflict resolution in customer service.
• Ability to travel between markets.
• Must maintain an acceptable driving record, a current driver’s license, and insurability.

Nice To Haves

• Master’s degree (MHA, MBA, or MSN).
• Experience with CMS medical necessity requirements and IRF experience.

Responsibilities

• Serve as the primary liaison to national and regional Medicare Advantage plans, promoting the clinical and financial value of inpatient rehabilitation services and strengthening payer relationships.
• Partner with contracting teams to negotiate, implement, and monitor payer contracts, ensuring reimbursement structures appropriately reflect IRF requirements.
• Lead improvements to referral intake and prior authorization processes to accelerate referral decisions, reduce operational turnaround times, and increase timely admissions.
• Collaborate with clinical liaisons, case managers, and rehabilitation physicians to ensure documentation clearly supports admission and coverage requirements before submission.
• Intervene in complex or delayed authorization requests and facilitate reviews between payer medical directors and physicians to help resolve issues.
• Lead strategic efforts to appeal payer denials, identify trends, and develop strategies, education, and processes to reduce further denials.
• Monitor and report performance metrics, including payer-specific referral-to-admission conversion rates, authorization turnaround times, denial rates, and length-of-stay variations.
• Collaborate with admissions, clinical, utilization review, revenue cycle, contracting, and hospital leadership teams to implement payer-specific action plans and drive measurable improvements in patient access, admissions, and reimbursement.
• Establish and lead regular meetings with key payers to address authorization challenges, resolve utilization issues, and strengthen working relationships.

What This Job Offers

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