Director of UM
Director of UM
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Job Description
SUMMARY
Curative is seeking an accomplished and dynamic leader to serve as Director of Utilization Management within our Medical Management division. This role provides strategic direction operational oversight and visionary leadership for our Utilization Management (UM) department. The successful candidate will drive quality efficiency and compliance across all UM functions.
The Director will oversee program development performance management and process optimization to ensure timely appropriate and cost-effective care delivery for our members. This leader will foster a culture of clinical excellence innovation and accountability while ensuring compliance with regulatory requirements and advancing Curatives mission to provide high-quality patient-centered care.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Program Leadership & Strategy
Develop implement and maintain the annual Utilization Management Program ensuring alignment with organizational goals and industry best practices.
Lead initiatives that optimize clinical quality patient safety and access to care while improving operational efficiency.
Establish and monitor performance metrics for turnaround times quality and service excellence.
Operational Oversight
Maintain adequate staffing levels and oversee recruitment training coaching and performance management of UM staff.
Ensure consistent compliance with prior authorization denials appeals complaints and telephone service standards.
Maintain Utilization Review Agency licensure and ensure adherence to all state and federal UM regulations benefit design requirements and HIPAA standards.
Policy & Process Development
Create revise and implement UM policies and procedures to meet evolving regulatory payer and clinical requirements.
Identify and implement technology solutions to improve accuracy timeliness and cost-effectiveness of UM processes.
Data Analysis & Reporting
Collect analyze and present UM performance data to internal and external stakeholders providing actionable insights and recommendations.
Conduct operational analyses develop action plans and lead process improvement initiatives to enhance service quality and efficiency.
Collaboration & Stakeholder Engagement
Partner with cross-functional teamsincluding Claims Provider Network and Qualityto streamline workflows and improve member outcomes.
Serve as a trusted advisor to executive leadership on UM trends compliance risks and strategic opportunities.
People Leadership & Development
Set clear expectations hold staff accountable and foster a culture of high performance and professional growth.
Mentor and coach leaders within the UM team to strengthen operational expertise and leadership capacity.
Regulatory Compliance
Ensure all UM activities meet US regulatory and quality system requirements (including 21 CFR 820).
Stay current on evolving UM regulations and industry standards to proactively adjust departmental strategies.
Work adhering to US regulatory and Quality System requirements (21 CFR 820 etc).
This position assumes and performs other duties as assigned
QUALIFICATIONS
Proven leadership experience in utilization management within a health plan managed care organization or similar healthcare setting.
Exceptional analytical data interpretation and decision-making skills.
In-depth knowledge of UM guidelines benefit design and medical necessity criteria (NCQA CMS state and federal).
Strong understanding of ambulatory and inpatient utilization patterns and efficiency drivers.
Demonstrated success in building high-performing teams and fostering collaboration across organizational levels.
Outstanding written and verbal communication abilities with the ability to present complex information clearly to diverse audiences.
Proficiency with Microsoft Excel Google Workspace and UM-related technology platforms.
Bachelors degree in Nursing Healthcare Administration or related field required; advanced degree or RN preferred.
EDUCATION and/or EXPERIENCE
At least five (5) years of progressive leadership experience in utilization management in a health insurance organization. Additional background in health care delivery systems statistical review skills and data management skills preferred.
Bachelors degree (B. A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.
CERTIFICATES LICENSES REGISTRATIONS
Registered Nurse with current license in good standing; BSN preferred
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and ability to adjust focus.
The noise level in the work environment is usually: Mild Moderate Severe
For this position the percentage of expected Travel is: 5% of the time
Required Experience:
Director
Employment Type
Full-Time
