Director, Utilization Management – Review

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

📋 Description

• Oversee utilization review functions to guarantee operational performance, quality, and compliance in clinical review activities.

• Manage utilization review operations, primarily focusing on post-payment reviews, including authorization workflows and clinical review processes.

• Set operational priorities and align team activities with the objectives of the organization.

• Track performance metrics, ensuring timeliness, accuracy, and consistency in decision-making.

• Ensure the standardized application of clinical criteria, policies, and review guidelines across all teams.

• Supervise the development and enhancement of workflows, procedures, and review processes.

• Examine paid claims to verify that the appropriate code aligns with the paid claim.

• Promote process improvements to maintain consistent, efficient, and compliant authorization decisions.

• Travel within the catchment area as necessary.

⛳️ Requirements

• Bachelor’s degree in Nursing or health and human services with three (3) years of Utilization Management experience; OR a Master’s degree in Nursing or health and human services with one (1) year of Utilization Management experience.

• Current North Carolina licensure as a Licensed Clinical Social Worker (LCSW), Licensed Clinical Mental Health Counselor (LCMHC), Licensed Marriage and Family Therapist (LMFT), Licensed Psychological Associate (LPA), Licensed Clinical Addictions Specialist (LCAS), or Registered Nurse (RN).

• Must possess a valid driver's license.

• Must reside in North Carolina.

• Ability to travel within the catchment area as required.

• All candidates must successfully pass a drug test as a condition of employment.

• Resume must detail employer name, service dates, average weekly hours worked, and key job responsibilities.

• Resume should include educational information, specifying degree type, date awarded, institution, and field of study.

• Resume must contain licensure/certification details, if applicable.

🏝️ Benefits

• A collaborative, mission-driven work environment.

• Competitive benefits and work-from-home options for the majority of positions.

• Opportunities for professional advancement within a diverse and inclusive culture.

• Flexible work schedules available for some roles with management approval.

• Work-from-home options offered for most positions.

• Health Insurance with no premium for employee coverage.

• Flexible Spending Accounts.

• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year.

• NC Local Government Retirement Pension (defined-benefit plan).

• 401k with a 5% employer match and immediate vesting.

• Public Service Loan Forgiveness (PSLF) qualifying employer.

• Quarterly stipend for remote work supplies.