Director, Utilization Management

Director Of Utilization ManagementThe Director of Utilization Management is a transformational clinical operations leader responsible for delivering strategic and operational oversight for Utilization Management (UM) teams. This high-impact forward-thinking leader drives clinical and operational excellence across all UM functions, including prior authorizations, concurrent reviews, and service requests while ensuring the delivery of medically necessary, cost-effective, and high-quality care in full compliance with CMS, NYSDOH, and contractual requirements.Duties/Responsibilities:Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requestsDevelop strong operational and leadership capabilities within the organization through performance improvement, career development, and coachingDevelop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirementsDeliver on Healthfirst's Mission by ensuring optimum quality of member care in a cost-effective mannerEnsure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entitiesDevelop and monitor appropriate metrics to maintain and improve department performanceCollect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvementLead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technologyServe as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiativesCollaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisionsPartner with technology and data teams to refine data governance and reporting, inform AI use cases, and performance monitoring frameworksSupport organizational change management for UM modernization efforts, fostering engagement, communication, and adoption of new technologies or processesAdvocate and actively participate as the clinical voice on various clinical committees and other clinical policy workgroupsAdditional duties as assignedMinimum Qualifications:Bachelor's degree in healthcare, business, or a related field from an accredited institution or equivalent work experienceProgressive leadership experience in healthcare management including work experience in a mid-senior management roleWork experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP).Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operationsWork experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS.Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions.Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.Preferred Qualifications:Master's degree in health-related areaProven ability to lead complex teams and manage interdisciplinary care models in a health plan or integrated delivery systemWork experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.Strategic thinker with strong operational discipline and capacity for executive-level decision-makingExperience working as a case manager for a long-term care programs such as PACE, MAP or MLTC.Strong computer skills, including, but not limited to word processing, spreadsheets, and databases.Compliance & Regulatory Responsibilities: Noted AboveLicense/Certification: N/AWE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to View email address on click.appcast.io or calling View phone number on click.appcast.io. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.Know Your RightsAll hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.Hiring Range*:Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555All Other Locations (within approved locations): $127,500 - $195,075As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.