Healthfirst

Director Utilization Management

Healthfirst

full-time

Posted on:

Location Type: Hybrid

Location: New York City • New York • 🇺🇸 United States

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Salary

💰 $150,800 - $230,690 per year

Job Level

Lead

About the role

  • 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 workgroups

Requirements

  • 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.
Benefits
  • medical, dental and vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions

Applicant Tracking System Keywords

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

Hard skills
performance improvementpolicy developmentdata analysisutilization managementregulatory compliancecost-effectiveness analysisclinical review processdata governancereporting frameworkshealthcare management
Soft skills
leadershipcoachingcommunicationcollaborationinfluenceengagementorganizational change managementproblem-solvingstrategic directionteam development
Certifications
Bachelor’s degree in healthcareBachelor’s degree in businessaccredited institution certification