Director Utilization Management MedStar Family Choice

Primary Duties and Responsibilities

• Leads enterprise-wide utilization management strategy across all health plans under a centralized clinical operation model.
• Standardizes UM policies workflows and clinical criteria application to ensure consistency and scalability across markets.
• Oversees prior authorization concurrent review retrospective review to ensure timely and compliant determinations.
• Ensures compliance with state Medicaid NCQA CMS and contractual requirements including turnaround time standards.
• Partners with medical directors to ensure appropriate clinical decision-making and consistent application of medical necessity criteria.
• Develops and monitors UM performance dashboards including denial rates overturn rates length of stay and turnaround times.
• Drives medical expense management initiatives by identifying utilization trends and implementing targeted interventions.
• Collaborates with Case Management leadership to ensure seamless transitions between UM and care coordination functions.
• Partners with pharmacy leadership to align utilization controls on high-cost drugs and specialty therapies.
• Oversees hospital utilization management including inpatient admission appropriateness DRG optimization and reduction strategies.
• Identifies and implements process improvement initiatives to increase operational efficiency and reduce variability.
• Prepares for a lead regulatory audits accreditation reviews and corrective action plans related to UM functions.
• Monitors and ensures compliance with evidence-based clinical criteria tools (e.g. InterQual ASAM) and internal policies.
• Leads workforce planning and staffing models to ensure appropriate caseload distribution and productivity standards.
• Supervises and develops UM managers and supervisors including performance evaluations and professional development.
• Collaborates with Finance and Actuarial team to analyze utilization trends cost drivers and forecast medical expense impact.
• Supports value-based payment models and alternative payment initiatives by aligning UM process with performance metrics.
• Develops escalation and peer review process to manage complex or high-risk clinical determinations.
• Ensures culturally competent and member- center decision-making balancing access quality and cost stewardship.
• Provides executive-level reporting and strategic recommendation to the VP of Clinical Operations and senior leadership
• Minimal Qualifications
  Education
  • Bachelor's degree Bachelor's degree in Nursing Social Work or related healthcare field required
  • Master's degree Master's degree in Nursing (MSN) Public Health (MPH) Healthcare Administration (MHA) Business Administration (MBA) or related field preferred
  Experience
  • 8-10 years years of managed care experience required and
  • 5-7 years Minimum 5 years utilization management leadership required and
  • Experience with centralized operations preferred and
  • Demonstrated experience in Medicaid managed care preferred
  Licenses and Certifications
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure in MD/DC Upon Hire required
  Knowledge Skills and Abilities
  • Deep understanding of state Medicaid CMS and NCQA requirements
  • Experience in medical necessity criteria tools (InterQual)
  • Strong data analytics and financial acumen
  • Change management expertise
  • Excellent executive communication skills.
  This position has a hiring range of : USD $120,702.00 - USD $238,222.00 /Yr.