Director, Utilization Management

General Summary of Position The Director of Utilization Management (UM) provides strategic and operational leadership for the health plan’s centralized utilization management function across both plans. This role ensures appropriate evidence-based utilization of services while maintaining regulatory compliance improving quality outcomes and driving cost-effective delivery. Under a centralized clinical operation model the Director aligns UM process across plans standardizes workflows optimizes technology and integrates closely with Case Management Pharmacy Quality and Provider Relations to support enterprise-wide performance goals. Primary Duties and Responsibilities Leads enterprise-wide utilization management strategy across all health plans under a centralized clinical operation model. Standardizes UM policies workflows and clinical criteria application to ensure consistency and scalability across markets. Oversees prior authorization concurrent review retrospective review to ensure timely and compliant determinations. Ensures compliance with state Medicaid NCQA CMS and contractual requirements including turnaround time standards. Partners with medical directors to ensure appropriate clinical decision-making and consistent application of medical necessity criteria. Develops and monitors UM performance dashboards including denial rates overturn rates length of stay and turnaround times. Drives medical expense management initiatives by identifying utilization trends and implementing targeted interventions. Collaborates with Case Management leadership to ensure seamless transitions between UM and care coordination functions. Partners with pharmacy leadership to align utilization controls on high-cost drugs and specialty therapies. Oversees hospital utilization management including inpatient admission appropriateness DRG optimization and reduction strategies. Identifies and implements process improvement initiatives to increase operational efficiency and reduce variability. Prepares for a lead regulatory audits accreditation reviews and corrective action plans related to UM functions. Monitors and ensures compliance with evidence-based clinical criteria tools (e.g. InterQual ASAM) and internal policies. Leads workforce planning and staffing models to ensure appropriate caseload distribution and productivity standards. Supervises and develops UM managers and supervisors including performance evaluations and professional development. Collaborates with Finance and Actuarial team to analyze utilization trends cost drivers and forecast medical expense impact. Supports value-based payment models and alternative payment initiatives by aligning UM process with performance metrics. Develops escalation and peer review process to manage complex or high-risk clinical determinations. Ensures culturally competent and member- center decision-making balancing access quality and cost stewardship. Provides executive-level reporting and strategic recommendation to the VP of Clinical Operations and senior leadership Minimal Qualifications Education Bachelor’s degree: Bachelor’s degree in Nursing Social Work or related healthcare field required Master’s degree: Master’s degree in Nursing (MSN) Public Health (MPH) Healthcare Administration (MHA) Business Administration (MBA) or related field preferred Experience 8-10 years years of managed care experience required and 5-7 years Minimum 5 years utilization management leadership required and Experience with centralized operations preferred and Demonstrated experience in Medicaid managed care preferred Licenses and Certifications RN – Registered Nurse – State Licensure and/or Compact State Licensure in MD/DC Upon Hire required Knowledge Skills and Abilities Deep understanding of state Medicaid CMS and NCQA requirements Experience in medical necessity criteria tools (InterQual) Strong data analytics and financial acumen Change management expertise Excellent executive communication skills. This position has a hiring range of USD $120,702.00 – USD $238,222.00 /Yr. In addition to your salary, MedStar Health offers a comprehensive healthcare package (including medical, dental and vision subject to eligibility requirements) and other benefits. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by MedStar Health. MedStar Health is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. The hiring range is the range MedStar Health, in good faith, believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on work experience, education and/or skill level, etc. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in MedStar Health’s sole discretion unless and until paid and may be modified at MedStar Health’s sole discretion, consistent with the law. Why MedStar Health? Strong emphasis on teamwork—our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark. Strategic focus on equity, inclusion, & diversity—we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization. Comprehensive total rewards package—including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more. More career opportunities closer to home—as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations. About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people. MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health entities that are federal government contractors are Equal Opportunity and Affinity. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health’s policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason. #J-18808-Ljbffr Communityplans