Director Utilization Management

About The Role The Director, Utilization Management (UM) will manage the Utilization Management team consisting of Clinicians and Non-Clinical support staff from Intake through Appeals processing. The ideal candidate will have a strong clinical background within a managed care setting, including a high-level understanding of the prior authorization process from intake at ingestion through reviews such as inpatient/concurrent, outpatient, retrospective, Physician reviews, and Appeals and Grievances processing. Primary Responsibilities Report to the Vice President of Clinical Operations and collaborate with other organizational leaders to ensure a regulatory compliant program. Support the executive team in implementing client onboardings with time-sensitive requirements. Support and grow the UM team through mentorship, ownership, and critical thinking. Establish cross-functional relationships with Clinical Program stakeholders for optimal partnership and integration. Ensure compliance with URAC and NCQA accreditation requirements and understand their roles within UM and the organization. Partner with Clinical Program leaders to address audit results and regulatory initiatives. Review reports for statistical and financial tracking to identify utilization trends and support financial forecasting. Understand regulatory, accreditation, and contractual obligations impacting daily UM operations. Lead processes to respond to operational questions and escalated UM cases from delegates, providers, and staff. Collaborate with Case Management and Disease Management leadership to ensure successful healthcare initiatives. Oversee UM department preparations and responses to regulatory audits, including corrective action plans. Participate in audits related to all aspects of UM. Analyze utilization metrics, develop strategies for outliers, and report regularly. Address member/provider/department complaints and escalations related to clinical reviews. Assist in identifying educational needs and training providers in collaboration with Provider Services. Participate in advisory groups and clinical committees. Essential Qualifications Active and unrestricted RN license. Bachelor’s degree in nursing or equivalent managed care experience. 8+ years of professional experience, including 5+ years managing UM operations. Experience with URAC and NCQA accreditation. Leadership experience in hiring, WFM, and staff performance management. Strong problem-solving, organizational, and decision-making skills. Proven team leadership abilities. Detail-oriented with excellent organizational and time management skills; able to work independently. Proficient in Microsoft Word, Excel, and Outlook. Preferred Qualifications Experience in a TPA environment. Experience with Case Management. Familiarity with call center operations. Experience in health platform development and implementation. About Brighton Health Plan Solutions Our team is committed to improving healthcare access and delivery. We foster a diverse, inclusive culture that encourages authenticity and respect. We partner with employers, health systems, providers, and TPAs, leveraging our expertise, provider networks, and technology to transform the health plan experience and solve healthcare challenges. Company Mission Transform the health plan experience by delivering outstanding products and services. Company Vision Redefine healthcare quality and value through innovative partnerships. DEI Purpose Statement We promote authenticity, diversity, inclusion, and belonging at every level. We are an Equal Opportunity Employer.

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