Director, Utilization Review

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

📋 Description

• Lead and manage the Utilization Review department effectively.

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

• Develop and uphold clinical guidelines, documentation standards, and review procedures.

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

• Ensure smooth integration between UR and Claims processes.

• Provide clinical expertise and documentation assistance for Appeals processes.

• Collaborate with Stop Loss teams on assessments and decisions regarding high-cost claims.

• Encourage efficiency in workflows across clinical and administrative functions.

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

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

• Oversee the creation and precision of denial and determination letters.

• Champion automation and digital workflow improvements within UR.

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

• Support real-time data exchange (EDI, integration platforms).

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

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

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

• Create dashboards and KPIs to assess productivity, compliance, and outcomes.

• Cultivate a culture of continuous improvement and accountability.

⛳️ Requirements

• Current Registered Nurse (RN) license required.

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

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

• Preferred experience in a Third Party Administrator (TPA) or health plan setting.

• Preferred knowledge of clinical platforms, workflow automation, and interoperability tools.

🏝️ Benefits

• Comprehensive medical, dental, and vision insurance with employer HSA contributions.

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

• 401(k) plan with employer matching 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.