Director, Utilization Management – Review

About the role

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Trillium believes that empowering others begins with supporting our team. We offer our employees: a collaborative, mission-driven work environment, competitive benefits and work-from-home options for most positions, opportunities for professional growth in a diverse inclusive culture. Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

Responsibilities

• Lead utilization review functions and be accountable for operational performance, quality, and compliance of clinical review activities.
• Set operational priorities, oversee workflows and performance, and drive process improvements to ensure consistent, efficient, and compliant authorization decisions.
• Direct utilization review operations, mostly post payment reviews, including authorization workflows and clinical review processes.
• Establish operational priorities and align team activities with organizational goals.
• Monitor performance metrics, including timeliness, accuracy, and consistency of decisions.
• Ensure standardized application of clinical criteria, policies, and review guidelines across teams.
• Oversee development and refinement of workflows, procedures, and review processes.
• Review paid claims to ensure appropriate code was enacted to be congruent with the paid claim.

Requirements

• Bachelor's degree in Nursing or health and human services and three (3) years of Utilization Management experience; OR Master's degree in Nursing or health and human services and one (1) year of Utilization Management experience.
• Active North Carolina licensure as one of: LCSW, LCMHC, LMFT, LPA, LCAS, RN.
• Valid driver’s license.
• Must reside within North Carolina.
• Must be able to travel within catchment as required.

Benefits

• Work-from-home options available for most positions.
• Health Insurance with no premium for employee coverage.
• Flexible Spending Accounts.
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year.