Director – Utilization Management

This is a fully remote position, open to applicants in Florida.

📋 Description

• Direct the utilization management team to ensure the appropriate application of policies, procedures, and processes that support optimal member outcomes.

• Oversee and manage daily Utilization Management operations, ensuring timeliness, quality, performance outcomes, provider interactions and experiences, and adherence to regulatory/compliance measures.

• Lead the utilization management team in performance management, improvement initiatives, and career advancement considerations.

• Establish and enforce team policies and procedures to guarantee compliance with corporate, state, and NCQA standards.

• Review, analyze, and report on utilization trends, patterns, and their impacts.

• Drive process improvements aimed at achieving cost-effective healthcare results and present findings to senior leadership.

• Create and implement policies and procedures that integrate best practices for effective utilization reviews.

• Develop utilization management strategies and provide recommendations that align with organizational objectives.

• Manage departmental budget elements while collaborating with senior leadership across departments.

• Implement onboarding, hiring, and training strategies for new team members.

• Lead and manage teams in a matrixed/cross-functional environment, adhering to tight deadlines and strict timeframes.

• Champion and facilitate change within the scope of responsibility.

• Perform other duties as assigned.

• Comply with all policies and standards.

⛳️ Requirements

• Bachelor's degree and over 7 years of relevant experience, including previous management experience.

• Equivalent experience may be considered in place of the degree and experience requirements, provided it demonstrates applicable knowledge, duties, scope, and skills reflective of this position.

• A minimum of 4 years of management experience is preferred.

• Expert knowledge of industry regulations, policies, and standards is preferred.

• RN - Registered Nurse - State Licensure and/or Compact State Licensure is preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• A flexible approach to work with options for remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation.