Director Of Utilization Management

Director of Utilization Management Overview

• The Director of Utilization Management oversees and directs the Utilization Management Department, ensuring compliance with Medicare requirements and promoting effective care coordination.
• Lead and manage the utilization review staff and program, ensuring alignment with organizational policies and procedures.
• Develop and implement policies and workflows consistent with CMS, Interqual, and DOH guidelines.
• Provide leadership in utilization management policy initiatives and oversee modifications to existing programs.
• Ensure compliance, timeliness, and completeness of care plans and documentation.
• Train new hires and provide ongoing staff development to maintain high standards.
• Monitor utilization reports to identify trends and implement effective strategies.
• Collaborate with leadership to expand and enhance the Utilization Management Department.
• Work in a hybrid environment with remote flexibility and occasional office presence.

Director of Utilization Management Key Responsibilities & Duties

• Provide day-to-day oversight of Utilization Management operations, ensuring alignment with organizational standards and goals.
• Develop and maintain policies and procedures for utilization management, ensuring compliance with Medicare requirements.
• Review and update guidelines and workflows based on CMS, Interqual, and DOH standards.
• Lead the development and implementation of training programs for the Utilization Review team.
• Prepare agendas and lead team meetings to ensure effective communication and collaboration.
• Monitor and analyze utilization reports to identify trends and implement improvements.
• Document case review findings and outcomes in accordance with organizational policies.
• Direct efforts in case management, utilization review, and precertification functions to achieve objectives within policy and budget.
• Determine staffing needs to support the Utilization Management and appeals processes.

Director of Utilization Management Job Requirements

• Associate of Applied Science (AAS) degree or equivalent educational background required.
• Minimum of 1 year of experience in utilization management, preferably within Medicare.
• Strong knowledge of CMS, Interqual, and DOH guidelines and standards.
• Proven leadership skills in managing and developing teams within healthcare operations.
• Experience in policy development and implementation within a healthcare setting.
• Ability to analyze utilization reports and identify trends for strategic planning.
• Excellent communication and organizational skills to lead meetings and training sessions.
• Familiarity with hybrid work environments and ability to adapt to flexible work arrangements.
• Commitment to compliance and quality standards in utilization management practices.