Director, Utilization Management & Operational Integrity

Medical Mutual employees must submit their applications through MySource. This is a hybrid role based in Brooklyn, OH, requiring four days per week on-site. Job Summary: Directs operations related to Commercial and Medicare acute and post‑acute care services to advance evidence-based policies, protocols, and practices to ensure efficient use of health care services and adherence to corporate and regulatory standards. Directs education, training, and auditing of all clinical services and operational staff. Responsibilities: Analyzes trends and identifies/implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data. Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization. Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results. Develops and implements utilization targets and drives accountability to benchmark metrics for staff productivity and membership management. Oversees the onboarding, education, training, and ongoing monitoring of all Clinical Services & Operations staff, ensuring appropriate decision‑making, application of criteria, documentation, and adherence to all regulatory requirements across all lines of business. Oversees the recruiting, performance, development and mentoring of staff. Ensures that team members are clinically competent and adequately trained to apply medical necessity criteria. Provides leadership and support to managers and supervisors. Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers. Leads talent management activities to develop and cultivate future leaders. Oversees the implementation of processes and systems to improve the efficiency and effectiveness of utilization management for inpatient services. Develops effective relationships with key health systems to improve communication, efficiency and effectiveness of utilization review process including leading clinical meetings to facilitate relationship building and identifying opportunities to advance access to EMRs/Portals. Serves as the subject matter expert liaison for acute and post‑acute service and/or leader on cross‑functional teams. Initiates cross functional/departmental discussions and initiatives to remove barriers and improve communications and workflows. Develops formal policies, procedures and workflows that effectively guide quality of work. Performs other duties as assigned. Qualifications: Education and Experience: Bachelor of Science in Nursing required. Master’s degree preferred. 8 years progressive experience in managed care utilization management, 5 years of which are in a leadership or project management capacity. Experience with process improvement techniques preferred. Professional Certification(s): Registered Nurse with current unrestricted license in state of residency required. Ability to obtain Ohio RN or Multi‑state RN Compact License within 60 days of date of hire. Ability to obtain additional RN licensure for multi‑state member management within 90 days of hire. Technical Skills and Knowledge: Comprehensive knowledge of NCQA accreditation standards and CMS regulations, HIPAA compliance and the ability to apply advanced concepts to Company operations. Strong computer skills (Microsoft Office, including Outlook, Excel, PowerPoint, Word). Demonstrated success with improving achieving productivity for authorization requests. Strong demonstrated communication and presentation skills. Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes. Strong knowledge of health insurance benefits and network plan designs. Ability to apply knowledge of health plans and industry trends to achieve positive outcomes. Thorough understanding of clinical knowledge, members' specific health plan benefits, and efficient care delivery processes. Knowledge of care delivery systems and continuum of acute through post‑acute care. Benefits and Compensation: We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset. Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more. On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters. Discounts at many places in and around town, just for being a Medical Mutual team member. The opportunity to earn cash rewards for shopping with our customers. Business casual attire, including jeans. Employee bonus program. 401(k) with company match up to 4% and an additional company contribution. Health Savings Account with a company matching contribution. Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority. Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self‑help resources and assistance with work/life benefits. Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time. After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption. Investment in You: Career development programs and classes. Mentoring and coaching to help you advance in your career. Tuition reimbursement up to $5,250 per year, the IRS maximum. Diverse, inclusive and welcoming culture with Business Resource Groups. Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Medical Mutual