Bradford Health Services

Director, Utilization Review

Bradford Health Services

full-time

Posted on:

Location Type: Office

Location: United States

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Job Level

Lead

About the role

  • Lead and manage the utilization review department, ensuring timely and accurate clinical reviews in accordance with regulatory and accreditation standards.
  • Develop and implement policies, procedures, and protocols to standardize utilization management practices across the organization.
  • Collaborate with clinical teams, case managers, and external payers to facilitate appropriate care delivery and resolve utilization-related issues.
  • Analyze utilization data and trends to identify opportunities for process improvements and cost containment.
  • Provide training, mentorship, and performance evaluations for utilization review staff to maintain high levels of clinical competency and compliance.
  • Ensure adherence to all federal, state, and payer regulations related to utilization review and healthcare compliance.
  • Serve as a subject matter expert on utilization management during audits, accreditation surveys, and internal reviews.
  • Partner with quality improvement and risk management teams to integrate utilization review findings into broader organizational initiatives.

Requirements

  • Bachelor’s degree in Nursing, Health Administration, or a related healthcare field.
  • Minimum of 5 years of progressive experience in utilization review, case management, or healthcare operations.
  • Strong knowledge of healthcare regulations, payer policies, and accreditation standards related to utilization review.
  • Demonstrated ability to analyze clinical data and implement process improvements.
  • Master’s degree in Nursing, Healthcare Administration, Public Health, or a related field (preferred).
  • Leadership experience managing clinical teams in a utilization management or related environment (preferred).
  • Certification in Case Management (CCM), Utilization Review (URAC), or related professional credentials (preferred).
  • Experience working within managed care organizations or health insurance companies (preferred).
  • Proficiency with healthcare data analytics tools and electronic health record (EHR) systems (preferred).
  • Familiarity with value-based care models and population health management (preferred).
Benefits
  • Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
  • Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
  • Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
  • Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
  • Student Loan Repayment – Available for nurses and therapists.
  • Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
  • Generous PTO – A robust paid time off policy to support work-life balance.
  • Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
utilization reviewcase managementhealthcare operationsclinical data analysisprocess improvementshealthcare regulationspayer policiesaccreditation standardsvalue-based care modelspopulation health management
Soft Skills
leadershipmentorshipcollaborationcommunicationanalytical thinkingproblem-solvingtrainingperformance evaluationorganizational skillssubject matter expertise
Certifications
Certified Case Manager (CCM)Utilization Review Accreditation Commission (URAC)