Senior Director Of Medical Review

Regency Plaza, 4643 S Ulster Street, Suite 700, Denver, Colorado, United States of America

Posted Tuesday, January 13, 2026 at 9:00 AM

The vision of Colorado Access is to have healthy communities transformed by the care that people want at a cost we can all afford. Our mission is to partner with communities and empower people through access to quality, affordable care.

We are a Colorado-based company, working to improve the health of our state. We care for individuals, families, and children who receive health care under Child Health Plan Plus (CHP+) and Health First Colorado (Colorado's Medicaid Program). Our focus is driving improvements in quality, member experience, outcomes, and cost. We are a mission-driven organization whose foundation is built by our vision, supported by our values and pillared by diversity, equity and inclusion.

• Find work/life balance:
  We offer PTO, floating holidays, nine company paid holidays, a hybrid work environment, an Employee Assistance Program and a 401K.
• Be a part of something bigger and make an impact:
  We serve the underserved and most vulnerable populations in our community through access to quality and affordable health care. No matter what you do for Colorado Access, you are impacting our community and making a difference.
• Sharpen your skills, learn, and grow:
  We support your continued development through tuition reimbursement, leadership training, promotion opportunities, performance evaluations, employee recognition, and a language pay stipend.

We are looking for a SENIOR DIRECTOR OF MEDICAL REVIEW who can help shape our vision and support our mission. Here is what the position will look like.

• Provides strategic direction and oversees the management and maintenance of multiple department deliverables striving for operational excellence (productivity, quality, SLAs, customer experience of services provided, etc.). Builds high performing teams with vision, leadership, goals and metrics. Serves as a role model for team members; takes action and inspires team members to embrace and implement culture initiatives. Provides awareness to department leaders and staff how their work impacts other departments, programs and the enterprise.
  
  Encourages collaboration and holds team members accountable for achieving outstanding results.
• Responsible for all management functions including hiring, training, planning and directing work, coaching and staff development, managing and evaluating performance, recognizing and rewarding employees, corrective action procedures and practices, addressing complaints and resolving problems. Develops and manages multiple department budgets.
• Works closely with Directors across the organization to make tactical and operational decisions that advance company strategies and goals and collaborates to deliver on company-wide deliverables/requirements.
• Oversees/leads projects and continuous improvement initiatives across multiple departments and/or cross-functional teams.
• Oversees the development and implementation of multiple department policies and procedures to ensure compliance with federal, state, local and company policies, rules and regulations.

• Own the end-to-end vision, strategy, and execution for Utilization Management (UM) and Pharmacy across all lines of business, ensuring alignment with organizational mission, values, and strategic imperatives.
• Direct, develop, and evaluate the UM program annually ensuring success through medical review and prior authorization, behavioral health management, clinical intake, and inpatient and outpatient review.
• Directs and develops specialty programs to support and ensure success of the UM program, inclusive of innovative programs that emphasize and utilize hospital collaborative work relationships, and internal and external partnerships; ensures compliance and administration of utilization policies through cost effective management of UM operations.
• Partner with leaders across the enterprise to design and evolve utilization management and pharmacy strategies that support competitive benefit design, affordability, and member and provider experience across all lines of business.
• Provide clinical and financial oversight of pharmacy team, pharmacy benefits, and pharmacy benefit manager (PBM), including contract management and value-based care incentives.
• Develops, secures approval and monitors and reports on area operating budget; forecasts spending levels, staffing requirements and resource needs for area.
• Serve as the organization’s go-to resource on state, federal, and NCQA requirements, shaping UM/Pharmacy policies, keeping the organization ahead of regulatory changes, and leading audits (EPSDT, MHPAEA, SUD Residential Review, and other compliance reviews).
• Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff…