Director of IRO Services

About the Role

The Director of IRO Services leads the strategy, operations, and regulatory integrity of the organization’s Independent Review Organization (IRO) and Utilization Review (UR) service line. This leader owns the full case lifecycle for medical necessity and appeals - ensuring every review is timely, clinically sound, and audit-ready. The role blends operational leadership (managing IRO/UR case managers and clinical reviewer workflows), regulatory stewardship (URAC accreditation, state IRO certification), and cross-functional partnership with clinical, compliance, technology, and client-facing teams.

This is a senior individual-contributor/manager hybrid role for a leader with deep hands-on expertise in independent medical review and utilization management, familiarity with Long-Term Services and Supports (LTSS) and Medicaid programs, and the ability to scale a high-volume, high-stakes review operation while maintaining exceptional quality, compliance, and turnaround times.

• Own end-to-end operational performance of the IRO and UR service line, from case intake through final determination, appeal, and closure.
• Set and monitor case-level KPIs (turnaround time, quality scores, audit pass rates, reviewer utilization) and drive continuous improvement across the intake-to-closure workflow.
• Build, lead, and develop a team of IRO/UR case managers, ensuring case documentation consistently meets quality, audit, and regulatory compliance standards.
• Design and enforce standard operating procedures for case triage, specialty-reviewer assignment, conflict-of-interest screening, decision-letter drafting, and case escalation.

• Serve as the organization’s subject-matter expert on IRO-governing regulations, including state IRO certification requirements and comparable frameworks in other states where the organization is certified.
• Own the organization’s relationship with URAC and other applicable accreditation bodies, leading audit preparation, standards interpretation, and continuous-improvement initiatives tied to IRO accreditation.
• Track federal and state regulatory/legislative changes affecting IRO, and disability-determination programs, and translate them into updated policies, workflows, and training.
• Maintain the compliance calendar and risk register for the IRO/UR service line; lead or support regulatory and accreditation audits as the primary operational point of contact.

• Partner with credentialing and clinical operations teams to ensure the reviewer network (specialty-matched M.D.s, D.O.s, and allied health professionals) remains primary-source verified, conflict-free, and audit-ready.
• Oversee quality assurance review of clinician determinations for accuracy, completeness, and alignment with clinical guidelines and regulatory requirements.
• Monitor reviewer performance and case outcomes; identify trends, gaps, or risk areas and drive corrective action plans.

Champion a culture of evidence-based, defensible decision-making across the review process.

• Act as a senior escalation point for complex, high-risk, or high-visibility cases, including disputes, complaints, and regulatory inquiries.
• Partner with product, engineering, and data teams to improve case-management systems, documentation tools, and workflow automation supporting the IRO/UR function.
• Serve as the primary relationship owner for state IRO clients and program administrators, building trusted partnerships, leading regular client touchpoints, addressing operational needs and escalations, and ensuring consistently strong service delivery.
• Collaborate with business development and account…