Director, Utilization Management

1 week ago Be among the first 25 applicants Get AI-powered advice on this job and more exclusive features. Direct message the job poster from Los Angeles County Firefighters Local 1014 Health Plan Job Title: Director of Utilization Management Employment Type: Full-time About the Role We are seeking an experienced and dedicated Director of Utilization Management to lead the UM operations of a PPO health plan. This position plays a critical leadership role in ensuring timely, compliant, and clinically appropriate utilization review processes. The Director will oversee a team of four staff: UM Manager, UM Nurse, and two UM Coordinators. Key Responsibilities Provide strategic leadership and day-to-day oversight of the Utilization Management department. Develop, implement, and refine UM policies and procedures in alignment with regulatory requirements and evidence-based standards. Monitor and ensure compliance with state, federal, and accrediting body standards (e.g., DMHC, NCQA, CMS). Supervise and support UM staff, including hiring, performance management, training, and professional development. Oversee and provide timely processing of prior authorizations, concurrent reviews, and retrospective reviews. Prepare and lead the department’s annual Quality Improvement Program (QIP) initiatives related to Utilization Management. Design and oversee inter-rater reliability testing for clinical staff to ensure consistency and accuracy in medical necessity determinations. Monitor and report on utilization data, trends, and key performance indicators to executive leadership. Develop and implement corrective action plans when needed to improve performance or compliance. Serve as the clinical and operational escalation point for complex UM cases and appeals collaboration. Collaborate cross-functionally with Claims, Enrollment, and other internal departments. Analyze utilization data and trends to drive efficiency and improve member outcomes. Report regularly to executive leadership on key performance indicators and departmental goals. Qualifications Required: -Valid Nursing License (RN or LVN) in the State of California (unrestricted and in good standing) -Minimum 10 years of verifiable experience in Utilization Management within a health plan, IPA, or MSO setting -Minimum 10 years in a senior management or director-level role -Demonstrated knowledge of PPO plan operations and clinical utilization review practices -Strong leadership, analytical, and organizational skills -Excellent communication and interpersonal abilities -Onsite position only – remote work is not available -Collaborative, mission-driven team focused on member care and regulatory excellence -Competitive salary commensurate with experience -100% employer-paid health coverage for employee and eligible dependents starting on Day One -Generous retirement plan with 8% employer contribution -Paid holidays, vacation, and professional development opportunities Job Type: Full-time Pay: $160,000.00 - $180,000.00 per year Health insurance Paid time off Experience: Management : 10 years (Required) License/Certification: Nurse License (RN/LVN) (Required) Ability to Commute: Seniority level

Seniority level Director Employment type

Employment type Full-time Job function

Job function Health Care Provider Industries Health and Human Services Referrals increase your chances of interviewing at Los Angeles County Firefighters Local 1014 Health Plan by 2x Get notified about new Director Healthcare jobs in

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