Senior Director of Utilization Management

TurningPoint Healthcare•Lake Mary, FL

About The Position

The Senior Director of Utilization Management (UM) provides strategic and operational leadership for the organization's Utilization Management functions, ensuring the delivery of high-quality, evidence-based, efficient, and compliant services. This leader is responsible for driving strategic vision, operational excellence, regulatory compliance, client satisfaction, workforce effectiveness, and continuous improvement across UM operations. The Senior Director serves as a key member of the Operations leadership team and partners closely with Clinical Operations, Quality, Technology, Product, Client Services, Implementation, Medical Policy/Coding and Growth teams to achieve organizational objectives and client commitments. This position is accountable for leading large teams through subordinate leaders, establishing scalable operating practices, monitoring performance outcomes, and ensuring UM services deliver consistent quality, timeliness, compliance, and value.

Requirements

Registered Nurse (RN) license required.
Bachelor’s degree in nursing, Healthcare Administration, Business Administration, or related field required.
7+ years of progressive healthcare operations leadership experience.
5+ years leading large-scale Utilization Management operations.
Demonstrated success managing leaders of leaders.
Experience supporting health plans, managed care organizations, delegated UM programs, or healthcare services organizations.
Strong understanding of NCQA, URAC, CMS, and state regulatory requirements.
Strategic Thinking
Executive Presence
Operational Excellence
Change Leadership
Financial Acumen
Client Relationship Management
Data-Driven Decision Making
Talent Development
Cross-Functional Influence
Continuous Improvement
Healthcare Regulatory Knowledge
Strong organizational, presentation, and interpersonal skills required.
Must be able to foster a positive, accountable, and productive work environment; build and motivate high-performing teams; communicate effectively across all levels of the organization; and use Microsoft Office applications and operational reporting tools effectively.

Nice To Haves

Master's degree preferred.
executive communication
client partnership
operational problem solving
process improvement
people leadership
change management
performance analytics
regulatory awareness
the ability to lead through influence in a matrixed environment.

Responsibilities

Develop and execute the long-term vision and strategy for Utilization Management operations.
Translate organizational objectives into operational plans, priorities, and measurable outcomes.
Identify opportunities to improve efficiency, quality, productivity, scalability, provider experience, and client satisfaction.
Lead operational transformation initiatives, including workflow modernization, automation readiness, and change management to support organizational growth.
Oversee day-to-day UM operations, including Prior Authorization, Concurrent Review, Retrospective Review, and related clinical review functions.
Ensure achievement of key performance indicators including productivity, quality, turnaround times, service levels, staffing effectiveness, and financial targets.
Monitor operational trends, volume drivers, and performance risks; implement timely mitigation plans when needed.
Establish, maintain, and continuously improve standardized processes, operating controls, reporting routines, and escalation pathways.
Lead and develop Directors, Managers, Supervisors, and other operational leaders.
Build leadership bench strength through coaching, succession planning, performance management, and talent development.
Foster a culture of accountability, collaboration, engagement, and continuous improvement.
Champion employee engagement, retention, recognition, and leadership communication strategies.
Serve as an executive operational contact for key client relationships and escalations.
Participate in client meetings, operational reviews, and strategic planning discussions.
Partner with Account Management and Growth teams to support client retention, implementation readiness, and expansion opportunities.
Ensure operational commitments, service level agreements, client-specific requirements, and issue-resolution expectations are consistently met.
Ensure compliance with NCQA, URAC, CMS, state, federal, and client-specific requirements.
Partner with Quality, Compliance, Medical Directors, and operational leaders to maintain audit readiness, regulatory adherence, and consistent application of UM criteria and processes.
Lead corrective action planning, root cause analysis, and process improvements related to audit findings, quality trends, and operational performance.
Participate in budget planning, workforce forecasting, and resource allocation as necessary.
Ensure efficient utilization of resources while maintaining quality, compliance, service, and employee engagement standards.
Partner with Technology and Product teams to enhance systems, automation, reporting, user experience, and workflow efficiency.
Collaborate with Client Implementation teams to ensure successful client transitions, workflow readiness, training alignment, and post-implementation stabilization.
Represent UM Operations in enterprise initiatives, governance forums, and organizational priorities as assigned.