Utilization Management Director

About the role

The Utilization Management Director will be responsible for building and leading UHSM’s first internal clinical utilization management function. This role will establish the structure, processes, policies, and team supporting end-to-end utilization management and clinical review functions, including medical necessity determinations, prior authorization, concurrent and retrospective review, Shared Medical Bills (SMB) clinical review, appeals support, and associated provider and member communications.

Responsibilities

• Develop and launch UHSM’s internal Utilization Management and Clinical Operations function, including workflows, policies, procedures, staffing models, documentation standards, and performance metrics.
• Inform design and implementation of a Salesforce-based clinical case management platform, partnering with internal and technical teams to define requirements, configure workflows, and optimize utilization management operations.
• Drive evaluation and selection of a clinical guideline engine (medical necessity criteria tool) and oversee integration with the case management system to support prior authorization, concurrent, and retrospective review workflows.
• Establish clinical review processes for prior authorization, pre-service review, concurrent review, retrospective review, medical necessity review, and SMB-related clinical evaluation and underwriting.
• Build and lead a clinical team, which may include UM nurses, clinical reviewers, care coordinators, clinical operations specialists, and administrative support staff.
• Create clear role definitions, training plans, quality review processes, and performance expectations for clinical team members.
• Serve as the organization’s subject matter expert on utilization management, clinical review operations, and medical necessity processes.

Requirements

• Department Buildout & Clinical Leadership
• Utilization Management Program Oversight
• Clinical Governance, Compliance & Quality
• Cross-Functional Partnership

Skills

• Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related clinical/healthcare field.
• Active, unrestricted Registered Nurse license or other applicable clinical license required.
• 7+ years of healthcare experience, including significant experience in utilization management, managed care, payer operations, clinical review, case management, or health plan operations.
• 5+ years of leadership experience managing clinical staff, UM nurses, case managers, or healthcare operations teams.
• Strong knowledge of utilization management functions, including prior authorization, medical necessity review, concurrent review, retrospective review, appeals support, and clinical documentation requirements.
• Experience using evidence-based clinical criteria, such as MCG, InterQual, Medicare guidelines, plan guidelines, or similar review criteria.
• Strong analytical skills with the ability to interpret utilization trends, claims data, clinical review data, and operational metrics.
• Excellent communication skills, including the ability to explain clinical review decisions, process requirements, and policy recommendations to both clinical and non-clinical stakeholders.

Benefits

Competitive salary and benefits package, including health, life, dental, and vision insurance, 403(b) with company match. The chance to make a meaningful impact in the lives of individuals and families seeking affordable, faith-based healthcare solutions. Great culture where you work with the founders and key stakeholders in a relaxed, but innovative atmosphere. UHSM is an Equal Opportunity Employer.

Pay

N/A

Schedule

N/A