Director, Utilization Review

About the Role

Minimum Qualifications

• Bachelor’s degree in Nursing, Health Administration, or a related healthcare field.
• Minimum of 5 years of progressive experience in utilization review, case management, or healthcare operations.
• Strong knowledge of healthcare regulations, payer policies, and accreditation standards related to utilization review.
• Demonstrated ability to analyze clinical data and implement process improvements.

Preferred Qualifications

• Master’s degree in Nursing, Healthcare Administration, Public Health, or a related field.
• Leadership experience managing clinical teams in a utilization management or related environment.
• Certification in Case Management (CCM), Utilization Review (URAC), or related professional credentials.
• Experience working within managed care organizations or health insurance companies.
• Proficiency with healthcare data analytics tools and electronic health record (EHR) systems.
• Familiarity with value-based care models and population health management.

Responsibilities

• Lead and manage the utilization review department, ensuring timely and accurate clinical reviews in accordance with regulatory and accreditation standards.
• Develop and implement policies, procedures, and protocols to standardize utilization management practices across the organization.
• Collaborate with clinical teams, case managers, and external payers to facilitate appropriate care delivery and resolve utilization-related issues.
• Analyze utilization data and trends to identify opportunities for process improvements and cost containment.
• Provide training, mentorship, and performance evaluations for utilization review staff to maintain high levels of clinical competency and compliance.
• Ensure adherence to all federal, state, and payer regulations related to utilization review and healthcare compliance.
• Serve as a subject matter expert on utilization management during audits, accreditation surveys, and internal reviews.
• Partner with quality improvement and risk management teams to integrate utilization review findings into broader organizational initiatives.

Skills

• The Director of Utilization Review utilizes strong clinical knowledge and leadership skills daily to guide the team in making informed decisions about patient care appropriateness and resource allocation. Analytical skills are essential for interpreting utilization data and identifying trends that inform strategic improvements. Effective communication and collaboration skills enable the Director to work closely with clinical staff, payers, and executive leadership to align utilization review processes with organizational objectives. Regulatory expertise ensures that all activities comply with evolving healthcare laws and payer requirements, minimizing risk and enhancing quality. Additionally, proficiency in healthcare technology and data systems supports efficient workflow management and accurate reporting.