Director, Utilization Management

About the role

This leader will oversee utilization management operations with a strong focus on quality outcomes, regulatory compliance, and effective review processes in a complex healthcare environment. The role will partner closely with senior leadership and cross-functional teams to strengthen performance, optimize resource use, and support member care. In addition, the director will guide process improvements, manage budget considerations, and lead the team through ongoing change with a steady, solutions-oriented approach.

Responsibilities

• Direct the utilization management team's daily operations to ensure quality member outcomes
• Lead and mentor the utilization management team, focusing on performance and career growth
• Ensure compliance with corporate, state, and NCQA standards in utilization management policies
• Analyze utilization data to identify trends and propose actionable improvement strategies
• Implement best practice policies for effective member utilization reviews
• Manage the department's budget and collaborate with senior leadership on financial strategies
• Champion change initiatives and ensure team adaptability within tight deadlines

Qualifications

• Bachelor's degree required
• 7+ years of related experience
• Prior management experience required; 4+ years preferred
• Expert knowledge of industry regulations, policies, and standards
• Strong analytical skills to assess utilization trends and develop effective strategies
• Experience collaborating inter-departmentally within a matrixed environment
• Registered Nurse (RN) state-based licensure preferred

Benefits

• Comprehensive health insurance benefits and wellness programs
• Professional development opportunities for career advancement
• Collaborative work environment fostering innovation and teamwork
• Flexible work arrangements to promote work-life balance
• Employee assistance programs for personal and professional support

Pay

$133,700 – $247,400 annually

Schedule

Remote - US based candidates only, no visa sponsorship available