Director, Utilization Management

At Duly Health and Care , you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician‑led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve. Benefits Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance. Access to a mental health benefit at no cost. Employer provided life and disability insurance. $5,250 Tuition Reimbursement per year. Immediate 401(k) match. 40 hours paid volunteer time off. A culture committed to community engagement and social impact. Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non‑physician team members once eligibility requirements are met. The Director of Utilization Management (UM) is responsible for the strategic and operational oversight of all delegated UM functions across Duly Health and Care. In this role, Duly operates under delegated authority from health plans, maintaining full accountability for utilization management performance, regulatory compliance, and clinical quality. The Director ensures that all UM activities—including prior authorization, medical necessity review, and care coordination—are executed in alignment with payer requirements, CMS and NCQA standards, and Duly’s clinical and operational priorities. This leader bridges internal operations, payer relationships, and delegated vendors to ensure high‑quality, cost‑effective care delivery while minimizing regulatory and operational risk. UM Oversight & Accountability Oversee all utilization management activities performed under payer delegation agreements. Ensure end‑to‑end accountability for UM performance, including timeliness, accuracy, and compliance. Monitor delegated vendors and internal UM teams executing prior authorizations, concurrent review, and discharge planning. Regulatory Compliance & Accreditation Ensure adherence to all federal, state, and payer‑specific requirements (e.g., CMS, NCQA, URAC). Maintain audit readiness for delegated UM functions, including documentation, policies, and workflows. Lead response efforts for audits, corrective action plans, and regulatory inquiries. Clinical & Operational Alignment Standardize UM policies, clinical criteria, and workflows across delegated functions. Ensure alignment between payer requirements and Duly’s internal clinical programs. Partner with medical directors to ensure evidence‑based, consistent decision‑making. Familiar with MCG Guidelines. Performance Management & Reporting Define, monitor, and report on key performance indicators (KPIs), including turnaround times, denial rates, and provider abrasion. Identify trends and implement continuous improvement initiatives to optimize performance. Develop executive‑level reporting for internal leadership and payer partners. Payer & Vendor Relationship Management Serve as the primary liaison between Duly, payer partners, and vendors. Lead regular operating reviews with health plans to ensure alignment and performance transparency. Escalate and resolve operational, clinical, or compliance issues. Team Leadership & Development Lead and develop UM leadership and operational teams. Foster a high‑performance culture focused on efficiency, quality, and accountability. Provide coaching and guidance to ensure consistent application of UM policies and clinical criteria. Risk Mitigation & Process Optimization Identify risks related to delegation (e.g., compliance gaps, operational inefficiencies, provider dissatisfaction). Implement standardized workflows, automation, and data integration strategies to improve visibility and control. Drive initiatives to reduce unnecessary utilization while maintaining high-quality patient outcomes. Qualifications Active Registered Nurse (RN) license preferred; advanced degree (MSN, MHA, MPH) preferred. 7–10+ years of experience in utilization management, including leadership experience with a strong operational background. Direct experience with delegated UM models and payer‑provider relationships strongly preferred. Deep knowledge of CMS, NCQA, and other regulatory/accreditation standards. Experience managing prior authorization, concurrent review, and case management programs. Strong analytical skills with the ability to translate data into actionable insights. Proven leadership experience managing teams and complex operations. Excellent communication and stakeholder management skills. Preferred Certifications: Certified Professional in Utilization Review (CPUR) Certified Case Manager (CCM) The compensation for this role includes a base pay range of $125,000–$188,000, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package. #J-18808-Ljbffr