Dir of Sr Utilization Management and Health Plan

Large Health System

The Director of Health Plan Utilization Management is a senior leader for the Health System Health Plan 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 is responsible for ensuring 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 Director oversees multiple teams performing this work. The Director reports to the Health System Medical Plan Chief Medical Officer and collaborates closely with them to develop, update and implement the Health System Medical Plan Utilization Management vision and strategy.

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, Health System Medical Plan Board of Directors, and other bodies, as required.

Attends and participates in Quality Management Committee, Health System Medical Plan 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 Health System, 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 Health System Medical Plan can provide documentation of compliance with contractual and regulatory requirements prior to audit by the State, CMS, DOI, etc. Must have a Master's Degree and RN