Director, Utilization Review

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

📋 Description

• Lead and manage the Utilization Review department.

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

• Develop and implement clinical guidelines, documentation standards, and review protocols.

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

• Ensure smooth integration between Utilization Review and Claims workflows.

• Provide clinical expertise and documentation assistance for Appeals processes.

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

• Enhance workflow efficiency throughout clinical and administrative operations.

• Ensure adherence to CMS, state, ERISA/non-ERISA, and accreditation regulations.

• Maintain documentation that is audit-ready and supports defensible clinical decisions.

• Oversee the formulation and accuracy of denial and determination correspondence.

• Work alongside Compliance and Legal to ensure regulatory compliance across all business lines.

• Drive automation and enhancements in digital workflows within Utilization Review.

• Facilitate interoperability among UR, Claims, Appeals, and vendor systems.

• Support real-time data exchange through EDI and integration platforms.

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

• Establish quality assurance programs, audit procedures, and performance benchmarks.

• Create and implement training programs for clinical and operational personnel.

• Develop dashboards and KPIs to evaluate productivity, compliance, and outcomes.

• Encourage a culture of continuous improvement and accountability.

⛳️ Requirements

• Current Registered Nurse (RN) license.

• At least 5 years of leadership experience in Utilization Review.

• Comprehensive knowledge of MCG guidelines, regulatory standards, and claims integration.

• Experience within a TPA or health plan setting is preferred.

• Familiarity with clinical platforms, workflow automation, and interoperability tools is preferred.

🏝️ Benefits

• Medical, dental, and vision insurance with employer contributions to HSA.

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

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

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

• Flexible Spending Accounts available.

• A collaborative workplace culture with regular company events.