Director of Utilization Management & Clinical Operations

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process. Full Time Professional Orange, CA, US 30+ days ago Requisition ID: 1082 Salary Range: $200,000.00 To $235,000.00 Annually Healthcare is increasingly unaffordable for many Americans. Most people believe they have two choices: increasingly expensive, restrictive employer insurance, or an ACA plan that keeps getting pricier. Many don't know there's a third, smarter option. WeShare Health is that option. WeShare Health’s mission is to make healthcare simpler, more affordable, and more human. We're a nonprofit, faith-inspired healthcare sharing organization where members contribute monthly to share one another's eligible medical expenses. We're proudly not insurance, and that's the point. Members access a national network of 1 million physicians at 30 to 60 percent less than comparable traditional insurance. Since 2018, WeShare Health has served more than 100,000 members and shared more than $50 million in medical expenses. Our purpose is clear: people before profit. WeShare Health is led by senior executives with deep experience across for-profit and nonprofit enterprises. We’re rated 4.6 out of 5 on Google Reviews, rated 4.7 on Trustpilot by members and certified as a Great Place To Work® by our employees. If you have a bias for action, enjoy challenges, and want to challenge the status quo to make an impact in a massive industry, WeShare Health might be the place for you! About this 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. This is a foundational leadership role for the organization. The Director will partner closely withSMB, Provider Services, Member Services, Compliance, Operations, and executive leadership toestablisha clinically sound, compliant, member-centered, and operationally efficientutilizationmanagement program. The ideal candidate is a licensed clinical professional with strongutilizationmanagement experience, payer or managed care knowledge, and the ability to build a department from the ground up. Key Responsibilities Department Buildout & Clinical Leadership 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 andselectionof 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, andSMB-related clinical evaluationandunderwriting. 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 onutilizationmanagement, clinical review operations, and medical necessity processes. Oversee the review of requested healthcare services to supportappropriate, evidence-based,timely, and consistent determinations. Ensure clinical reviews are based on relevant clinical documentation, plan/program guidelines, recognized clinical criteria, and applicable regulatory or accreditation standards. Develop processes for urgent and non-urgent reviews, provider communication,additionalinformation requests, peer review escalation, and documentation of determinations. Monitorutilizationtrends, high-cost services, inpatient stays, readmissions, out-of-networkutilization, gaps in care coordination, and other clinical cost drivers. Partner with leadership toidentifyopportunities to improve clinical outcomes, reduce avoidable costs, and strengthen member/provider experience. Clinical Governance, Compliance & Quality Develop policies and procedures aligned withappropriate utilizationmanagement standards, including medical necessity review, clinical criteria use, denial documentation, appeals support, and peer review escalation. Partner with Compliance to ensure utilization management processes meet applicable federal, state, contractual, and organizational requirements. Support audit readiness andmaintain accuratedocumentation for clinical decisions, review rationale, notifications, appeal support, and quality monitoring. Establish quality assurance processes to monitor clinical review accuracy, timeliness, consistency, and documentation quality. Stay current on utilization management best practices, payer operations, healthcare regulations, and accreditation standards such as NCQA or URAC, as applicable. Cross-Functional Partnership Collaborate withtheSMBteamtosupport clinical review of complexSMBs, high-dollarSMBs, disputedSMBs, coding-related clinical questions, and medical necessity concerns. Partner with Provider Services to improve provider communication, documentation requests, prior authorization workflows, and provider education. Partner with Member Services to ensure clinical review processes are clearlycommunicated,and member escalations are handled appropriately. Work with executive leadership to define the long-term clinical team structure, including future roles such as Medical Director, UM Nurse, Case Manager, Clinical Appeals Nurse, or Care Management Manager. Support vendor evaluation and management for clinical review tools,utilizationmanagement platforms, medical necessity criteria, peer review vendors, case management resources, or external clinical consultants. Metrics & Reporting Develop dashboards and reporting forutilizationmanagement activity, turnaround times, approval/denial trends, appeal outcomes, inpatient days, high-cost services, reviewer productivity, quality audit results, and provider/member escalations. Use data toidentifyprocess gaps, training needs, cost-containment opportunities, and clinical risk areas. Present findings and recommendations to executive leadership in a clear, actionable manner. Minimum Qualifications 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. Multistate Nurse Licensure Compact license preferred. Candidate must be eligible and willing to obtain additional state licensure if required based on organizational needs, member geography, applicable regulations, and assigned clinical responsibilities. 7+years of healthcare experience, includingsignificant experienceinutilizationmanagement, 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. Demonstrated experience managing departmental budgets, including headcount planning, vendor spend, and operational cost oversight Strong knowledge ofutilizationmanagement functions, including prior authorization, medical necessity review, concurrent review, retrospective review,appealssupport, and clinical documentation requirements. Experience using evidence-based clinical criteria, such as MCG, InterQual, Medicare guidelines, plan guidelines, or similar review criteria. Experience developing or improving clinical workflows, policies, procedures, training materials, and quality review processes. Strong understanding of payer, TPA, managed care, health plan, or healthcare cost-containment operations. Ability to build a department, lead change, influence cross-functional partners, and create structure in a developing environment. Strong analytical skills with the ability to interpretutilizationtrends, 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. Preferred Qualifications Master’s degree in Nursing , Healthcare Administration, Business Administration, Public Health, or a related field. Experience building a utilization management, case management, clinical operations, or care management function from the ground up. Prior experience in a health plan, managed care organization, TPA, self-funded employer plan, medical group, IPA, ACO, or healthcare sharing organization. Experience with NCQA, URAC, CMS, ERISA, ACA, HIPAA, or stateutilizationmanagement requirements, as applicable to the organization. Certification such as CCM, ACM, CPHQ, CPUM, CPUR, CPMA, or similar healthcare quality/utilization/case management credential. Experience working with Medical Directors, physician reviewers, peer-to-peer review processes, clinical appeals, and external review vendors. Experience selecting or implementing UM platforms, clinical documentation systems, workflow tools, or medical necessity criteria systems. Experience with budget ownership, P&L accountability, or financial stewardship within a clinical operations, health plan, or managed care environment. Knowledge of claims operations, provider contracting, provider dispute resolution, coding, billing, or healthcare reimbursement. What we offer Competitivesalaryand benefits package, including health, life dental, and vision insurance, 403(b) with company match The chance to make a meaningful impactinthe lives of individuals and familiesseekingaffordable, faith-based healthcare solutions Great culture where you work with the founders and key stakeholders in a relaxed, but innovative atmosphere WeShare Health is an Equal Opportunity Employer. Our business is fast-paced and will continue to evolve. As such, the duties and responsibilities of this role may be changed as directed by the Company at any time to promote and support our business needs. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, protected veteran status, or any other basis protected by applicable law and will not be discriminated against on the basis of disability. #J-18808-Ljbffr Weshare