Director, Utilization Management – Prior Authorization
Fallon Health
full-time
Posted on:
Location Type: Hybrid
Location: Worcester • Massachusetts • 🇺🇸 United States
Visit company websiteSalary
💰 $155,000 - $175,000 per year
Job Level
Lead
About the role
- Provide strategic leadership and oversight for clinical and operational utilization management activities
- Oversee all administrative, operational and clinical functions related to outpatient and inpatient management
- Ensure program compliance with all federal regulatory and state mandates
- Responsible for hiring appropriate personnel to review medical cases
- Manage data and predictive analytics to improve efficiency
- Define performance expectations and goals for staff and monitor their work
Requirements
- Master’s degree in health administration or business preferred
- Bachelor’s degree in nursing or related health field required
- Massachusetts Nursing Licensure
- Broad experience in managed care and/or integrated delivery systems
- Significant experience in regulatory and accreditation compliance for Medicare, Medicaid
- Minimum of ten years clinical experience, at least five in managed care or ambulatory clinical operations
Benefits
- Health insurance
- Paid time off
- Flexible work arrangements
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
data analyticspredictive analyticsutilization managementclinical operationsoperational managementperformance managementregulatory complianceaccreditation compliancemanaged careambulatory care
Soft skills
strategic leadershipoversightstaff managementgoal settingmonitoring
Certifications
Massachusetts Nursing Licensure