Director, Utilization Management

The Director of Utilization Management is a transformational clinical operations leader responsible for delivering strategic and operational oversight for Utilization Management (UM) teams. This high-impact forward-thinking leader drives clinical and operational excellence across all UM functions, including prior authorizations, concurrent reviews, and service requests while ensuring the delivery of medically necessary, cost-effective, and high-quality care in full compliance with CMS, NYSDOH, and contractual requirements.

• Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests
• Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching
• Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements
• Deliver on Healthfirst’s Mission by ensuring optimum quality of member care in a cost-effective manner
• Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
• Develop and monitor appropriate metrics to maintain and improve department performance
• Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement
• Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology
• Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives
• Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions
• Partner with technology and data teams to refine data governance and reporting, inform AI use cases, and performance monitoring frameworks
• Support organizational change management for UM modernization efforts, fostering engagement, communication, and adoption of new technologies or processes
• Advocate and actively participate as the clinical voice on various clinical committees and other clinical policy work groups
• Additional duties as assigned

• Bachelor’s degree in healthcare, business, or a related field from an accredited institution or equivalent work experience
• Progressive leadership experience in healthcare management including work experience in a mid-senior management role
• Work experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP)
• Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
• Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS
• Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions
• Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment

• Master’s degree in health-related area
• Proven ability to lead complex teams and manage interdisciplinary care models in a health plan or integrated delivery system
• Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements
• Strategic thinker with strong operational discipline and capacity for executive-level decision-making
• Experience working as a case manager for a long‑term care programs such as PACE, MAP or MLTC
• Strong computer skills, including but not limited to word processing, spreadsheets, and databases
• Strategic thinker with strong operational discipline and capacity for executive-level decision-making
• Compliance & Regulatory Responsibilities:
  Noted Above

License/Certification: N/A

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555
• All Other Locations (within approved locations): $127,500 - $195,075

As a candidate for…