Director, Utilization Review

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

📋 Description

• Oversee and direct the operations of the utilization review department, ensuring that clinical reviews are conducted promptly and accurately in alignment with regulatory and accreditation requirements.

• Formulate and execute policies, procedures, and protocols to standardize utilization management practices throughout the organization.

• Work in collaboration with clinical teams, case managers, and external payers to ensure appropriate care delivery and address utilization-related challenges.

• Examine utilization data and trends to uncover opportunities for process enhancement and cost reduction.

• Provide training, mentorship, and performance evaluations for staff involved in utilization review.

• Guarantee compliance with federal, state, and payer regulations associated with utilization review and healthcare compliance.

• Act as a subject matter expert during audits, accreditation assessments, and internal reviews.

• Collaborate with quality improvement and risk management teams to incorporate utilization review findings into broader organizational strategies.

• Serve as a bridge between clinical staff, payers, and leadership to align utilization review efforts with organizational objectives and best practices in healthcare.

⛳️ Requirements

• A bachelor’s degree in Nursing, Health Administration, or a related healthcare discipline.

• At least 5 years of progressive experience in utilization review, case management, or healthcare operations.

• Comprehensive knowledge of healthcare regulations, payer policies, and accreditation standards relevant to utilization review.

• Proven ability to analyze clinical data and execute process improvements.

• A master’s degree in Nursing, Healthcare Administration, Public Health, or a related field is preferred.

• Leadership experience in managing clinical teams in a utilization management or similar environment is preferred.

• Certification in Case Management (CCM), Utilization Review (URAC), or other related professional credentials is preferred.

• Experience working within managed care organizations or health insurance companies is preferred.

• Proficiency in healthcare data analytics tools and electronic health record (EHR) systems is preferred.

• Familiarity with value-based care models and population health management is preferred.

🏝️ Benefits

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – 401(k) plan through Voya.

• Generous PTO – Robust paid time off policy.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

• Great Place To Work® Certification and a supportive, rewarding workplace culture.