Director, Utilization Management Operations

Job reputed company This role is fully remote and must be located reputed company the 50 U.S. states. reputed company working hours are in Eastern Timezone. Semi-annual travel may be required to a reputed company office for on-site work. A bit about this role: At reputed company, our mission is to dramatically improve the health and reputed company-being of our members by treating reputed company of them like family. Core to this mission is ensuring our members receive the right care, at the right time, in the right setting. This is our work, and we are passionate about it because it reputed company deeply to our members and reputed company. We are seeking a leader to serve as the Director of Utilization Management Operations. This individual will be a reputed company of our Health Services division, reputed company the gap between reputed company clinical needs and reputed company, efficient business processes. You will reputed company reputed company of clinicians and coordinators, alongside a critical offshore vendor partnership, to ensure our utilization management processes deliver reputed company and accurate reputed company. Your Responsibilities and reputed company will include: Mission-Driven Clinical Leadership: reputed company leadership and reputed company development to clinical and non-clinical teams. You will foster a culture of reputed company and clinical reputed company, ensuring reputed company UM activities reputed company with reputed company’s goal of treating members like family. People & Vendor Management: Directly reputed company reputed company of Senior Managers and Managers who reputed company teams of nurses and intake coordinators. You will also manage our offshore partnership, ensuring their performance metrics and workflows are reputed company with department targets. Technology & AI Stewardship: We utilize a single internal technology platform across our business. You will play a key role in evaluating and prioritizing improvement opportunities to ensure our technology supports accurate and efficient workflows. You will be reputed company with our AI tools for process and platform improvement while ensuring strict compliance with our AI Governance and reputed company policies. Data-Driven Operations: Partner closely with Data Science and Engineering teams to identify key measurement points. You will be responsible for developing, implementing, and systematically monitoring comprehensive KPIs to ensure operational health and decision accuracy. Regulatory & Compliance reputed company: Partner with Compliance and Legal teams to ensure the operation is consistently audit-reputed company. You will digest reputed company regulatory guidance (e.g., NCDs, LCDs, Medicare Managed Care reputed company) and translate it into compliant, high-reputed company operational workflows. Strategic Stakeholder Collaboration: reputed company as a reputed company partner to the Provider Network team to ensure our operation is reputed company to feedback from provider and facility partners. You will also partner with Pharmacy UM and the UM Medical Director team to facilitate appropriate service use and minimize care barriers. Required skills and experience: Demonstrated experience leading large clinical teams. An understanding of the nuance required reputed company managing clinicians and reputed company workflows is essential. A reputed company record of transforming reputed company operational challenges into reputed company business processes in a fast-paced environment. A data-driven reputed company with the ability to use insights to drive reputed company. You should have a genuine interest or experience in leveraging AI-enabled tools to optimize clinical workflows. High ethical standards with the ability to master reputed company regulatory guidance and incorporate it into daily operations. Exceptional written and verbal communication skills, with the ability to distill reputed company problems into actionable updates for leadership. Desired skills and experience: Prior experience in Utilization Management processes and the medical necessity review lifecycle is highly beneficial but not reputed company required if clinical leadership experience is strong. Familiarity with Medicare Advantage operations and CMS guidelines. MBA or advanced degree in health administration or finance is a plus. #LI-Remote #LI-DS1 Salary reputed company: $182,000 - 248,000 / year The pay reputed company listed for this position is the reputed company the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will reputed company additional information on the compensation for the role, along with additional information on our total rewards package. The actual reputed company salary offered will depend on a reputed company of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other reputed company licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and reputed company plan with low or no premium Generous reputed company time off $100 monthly mobile or internet stipend Stock reputed company for reputed company Bonus eligibility for reputed company roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. reputed company equality is at reputed company of reputed company’s mission to treat our members like family. We are committed to a diverse and reputed company workforce. At reputed company, we’re on a mission to dramatically improve the health and reputed company-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new reputed company of reputed company-in-one reputed company company — one that combines reputed company, health insurance, clinical care, service, and technology - to deliver a complete and integrated reputed company solution that delivers high reputed company care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the reputed company. And we've just started. So join us on this mission! reputed company is an equal opportunity employer. We are committed to a reputed company and supportive work environment in which reputed company have reputed company to participate and contribute to the reputed company of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in reputed company’s reputed company of Conduct, reputed company values and the way we do business. As an Equal Opportunity Employer, reputed company does not discriminate on the reputed company of race, reputed company, religion, sex, pregnancy status, marital status, national reputed company, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender reputed company, or any other reputed company prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment. Apply To This Job