Director, Utilization Review

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

📋 Description

• Provide leadership and oversight for the Utilization Review department.

• Ensure consistent, evidence-based determinations of medical necessity.

• Establish and enforce clinical guidelines, documentation standards, and review protocols.

• Maintain alignment with MCG guidelines and internal clinical governance standards.

• Facilitate seamless integration between UR and Claims workflows.

• Offer clinical expertise and documentation support for Appeals processes.

• Collaborate with Stop Loss teams on reviews and determinations of high-cost claims.

• Ensure compliance with CMS, state regulations, ERISA/non-ERISA, and accreditation standards.

• Drive automation and enhancements of digital workflows within UR.

• Enable interoperability across UR, Claims, Appeals, and vendor systems.

• Utilize analytics to inform utilization trends, clinical outcomes, and population health initiatives.

• Establish quality assurance programs, audit processes, and performance standards.

⛳️ Requirements

• Active Registered Nurse (RN) license.

• A minimum of 5+ years of leadership experience in Utilization Review.

• Strong understanding of MCG guidelines, regulatory standards, and claims integration.

• Preferred experience in a TPA or health plan environment.

• Preferred familiarity with clinical platforms, workflow automation, and interoperability tools.

🏝️ Benefits

• Medical, dental, and vision coverage with employer HSA contributions.

• Company-paid life, AD&D, and disability insurance.

• 401(k) with up to a 6% employer match.

• Generous paid time off, sick time, and over 10 paid holidays.

• Flexible Spending Accounts.

• A collaborative culture with regular company events.