Senior Director, Health Plan Utilization Management - Denver Health Medical Plan (Must Live in Colorado. Weekly On Site Requirement)

Must live in Colorado. This is a hybrid role located in Denver, Colorado with a requirement of being in the office 3 days per week.

About the Role

The Senior Director of Health Plan Utilization Management is a senior leader for the Denver Health Medical Plan (DHMP) with responsibility for providing strategic and operational leadership for all utilization management functions across the organization. This area has unique regulatory and contractual compliance requirements for each line of business. This role ensures clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations while supporting high-quality member outcomes and provider collaboration.

The Senior Director partners closely with Operations, Network Management, Quality, Compliance, and Finance to align utilization management strategy with organizational goals. In this capacity, the Senior Director oversees multiple teams performing this work and reports to the DHMP Chief Medical Officer, collaborating closely to develop, update, and implement the DHMP Utilization Management vision and strategy.

Responsibilities

• Assures that all staff are appropriately trained on all relevant software programs and applications necessary to perform their job functions.
• Participates in presentation of reports to the Operations Team, DHMP Board of Directors, and other bodies, as required.
• Attends and participates in Quality Management Committee, DHMP Operations Team meetings, Utilization Management Committee, enterprise Care Coordination meetings, and other related meetings and activities as required.
• Serves as an issue-related or escalation liaison between Utilization Management and other departments and/or agencies both within Denver Health, contractors, and/or plan members.
• Oversees the maintenance, development, implementation, and continuous improvement of UM policies and procedures and management of information systems to accomplish UM goals for all contracted populations.
• Develops, analyzes, and presents reports on productivity, quality, and outcomes.
• Ensures DHMP can provide documentation of compliance with contractual and regulatory requirements prior to audit by the State, CMS, DOI, etc.
• Develops, implements, and evaluates formal educational activities and follows up on issues identified through educational activities. Brings new knowledge to staff meetings.
• Works closely with DHMP Compliance Officer to ensure all DHMP lines of business operational performance meets or exceeds regulatory requirements, including policies, procedures, and reporting. Acts as a voting member of the DHMP Compliance Committee.
• Ensures routine and ad hoc reporting is available, which may include utilization data by setting (inpatient, outpatient, and Pharmacy), or other special projects supporting the overall goals of DHMP.

Requirements

• Master's degree required; graduation from an accredited educational program for Nursing or Physician’s Assistants required.
• Seven years of experience in administration in managed care, health plan administration, or healthcare provider organizations required.
• Minimum of five years of supervisory and management experience required.
• 1-3 years of Health Plan or healthcare experience with various lines of business including Medicare, Medicaid, CHP, Exchange, and/or Commercial Plans required.
• 1-3 years of experience in managing vendors required.

Skills

• Knowledge of regulatory and accreditation standards for health plan or healthcare operations required.
• Strong program development, analysis, and evaluation skills required.
• Demonstrated excellence in managing people and processes.
• Strong leadership skills with ability to engage multidisciplinary clinical and non-clinical teams to solve complex problems.
• Strong knowledge and experience in utilization principles, concepts, and strategies preferred.
• Ability to develop and maintain effective relationships with internal and external stakeholders.

Pay

$143,800.00 - $237,300.00 / yr

Benefits

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 holidays.
• 100% paid parental leave up to 6 weeks.
• Immediate eligibility for retirement plans with employer contribution up to 9.5%.
• Generous medical, dental, vision plans in addition to employer-paid disability and life insurance.
• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center.
• Free RTD EcoPass (public transportation).
• Childcare discount programs & exclusive perks on large brands, travel, and more.
• Tuition reimbursement & assistance.
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways.
• Professional clinical advancement program & shared governance.
• Public Service Loan Forgiveness (PSLF) eligible employer + free student loan coaching and assistance navigating the PSLF program.
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer.

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan, and Denver Health Foundation. As Colorado’s primary and essential safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.