Director, Utilization Management Operations

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

📋 Description

• Take ownership of SLA performance for administrative tasks that support the authorization review process within utilization management.

• Hold a dotted-line responsibility for the turnaround times of Part B medical authorizations, collaborating with clinical leaders to track performance, identify risks, and eliminate administrative obstacles.

• Analyze and redesign the complete administrative processes, including authorization intake, clinical information requests, facility census checks, notifications, and follow-up.

• Collaborate with the Product and Engineering teams to influence the Orinoco technology roadmap.

• Deploy integrated AI tools to minimize manual labor and manage the growth of administrative capacity.

• Create measurable and transparent processes while defining and monitoring KPIs such as timeliness, cost per authorization, quality, and provider experience.

• Lead and mentor approximately 50 onshore UM Administrative Coordinators and their supervisors.

• Oversee an offshore vendor partnership that supports more than 250 administrative team members.

• Work with the Provider Network to integrate provider and facility requirements into the processes.

• Design outreach strategies, notifications, and follow-up touchpoints for members and providers.

• Collaborate with the Senior Director of UM, UM Medical Directors, Compliance, Provider Network, Data Science, and Engineering teams.

• Ensure that operations remain aligned and consistently audit-ready.

⛳️ Requirements

• A sincere commitment to treating members as family, believing that operational excellence and empathy are complementary.

• Proven experience in leading high-volume operations that consistently achieve SLA performance.

• Ability to deconstruct complex, multi-step processes and lead the development of simpler, scalable alternatives.

• Proficiency in working within workflows and data, utilizing both to drive decisions and accountability.

• Experience collaborating with product and engineering teams.

• Genuine enthusiasm for employing AI-enabled tools to revolutionize work processes.

• Experience managing vendor partners to uphold clear performance and quality standards.

• Outstanding written and verbal communication abilities.

• A Bachelor's degree is required.

• Experience in payer operations, utilization management, claims, provider revenue cycle, or a comparable high-volume healthcare setting is preferred.

• Familiarity with Medicare Advantage operations and CMS requirements is a plus.

• An MBA or advanced degree in health administration or finance is an advantage.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.

• Generous paid time off policy.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Comprehensive parental leave program.

• 401K program.

• Bonus eligibility for all roles, excluding Director and above.

• Commission eligibility for Sales roles.