Director, Utilization Review
RemoteLucedale, Mississippi, United States
Job Summary
Lead and manage the utilization review department, ensuring timely and accurate clinical reviews in accordance with regulatory and accreditation standards. Develop policies, procedures, and protocols to standardize utilization management practices across the organization. Collaborate with clinical teams, case managers, and external payers to facilitate appropriate care delivery and resolve utilization-related issues. Analyze utilization data and trends to identify opportunities for process improvements and cost containment. Provide training, mentorship, and performance evaluations for utilization review staff to maintain high levels of clinical competency and compliance. Ensure adherence to all federal, state, and payer regulations related to utilization review and healthcare compliance. Serve as a subject matter expert on utilization management during audits, accreditation surveys, and internal reviews. Partner with quality improvement and risk management teams to integrate utilization review findings into broader organizational initiatives.
Required Qualifications
- Bachelor's degree in Nursing, Health Administration, or a related healthcare field
- Minimum of 5 years of progressive experience in utilization review, case management, or healthcare operations
- Strong knowledge of healthcare regulations, payer policies, and accreditation standards related to utilization review
- Demonstrated ability to analyze clinical data and implement process improvements
- Strong clinical knowledge
- Leadership skills
- Analytical skills
- Effective communication and collaboration skills
- Regulatory expertise
- Proficiency in healthcare technology and data systems
Desired Qualifications
- Master's degree in Nursing, Healthcare Administration, Public Health, or a related field
- Leadership experience managing clinical teams in a utilization management or related environment
- Certification in Case Management (CCM), Utilization Review (URAC), or related professional credentials
- Experience working within managed care organizations or health insurance companies
- Proficiency with healthcare data analytics tools and electronic health record (EHR) systems
- Familiarity with value-based care models and population health management
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