Director, Utilization Management & Clinical Operations

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 120,000 - 190,000; Full time

Job summary

CommunityCare HMO Inc. in Tulsa, Oklahoma, seeks a Director of Utilization Management to provide strategic and operational leadership for the health plan's Physical Health Utilization Management department reporting to the Chief Medical Officer.

You will lead a large team, drive data-driven strategies to improve clinical appropriateness, affordability, efficiency, and quality, and ensure compliance with regulatory standards. This role requires RN licensure and senior leadership experience.

Qualifications

• Expert knowledge of health plan utilization management operations, benefit administration, medical necessity review, clinical criteria, regulatory requirements, accreditation standards, and delegated oversight.
• Ability to analyze utilization, cost, quality, and operational data and translate findings into strategy and measurable results.
• Experience leading complex operations, improving workflows, and ensuring service, quality, compliance, and financial performance.

Responsibilities

• Direct strategy and daily operations of Physical Health Utilization Management across prospective, concurrent, and retrospective review.
• Set workload, staffing, coverage, productivity, quality, documentation, escalation and turnaround times; address risks.
• Lead Utilization Management supervisors and manage workforce planning, performance, and leadership development.
• Analyze utilization, cost, quality, provider, and operational data to identify trends and drive improvements.
• Evaluate impact of prior authorization and other utilization controls; recommend changes.
• Ensure consistent application of benefits, criteria, policies, and regulatory requirements; maintain readiness.
• Collaborate across clinical and operational teams to resolve issues and implement improvements.
• Evaluate and implement utilization management technology with governance oversight.

Skills

Utilization management

Benefit administration

Medical necessity review

Regulatory compliance

Quality accreditation

Delegated oversight

Data analysis

Education

Bachelor of Science in Nursing

Master's degree in nursing or healthcare admin

Tools

Microsoft Office

Analytics tools

Job description

CommunityCare HMO Inc. in Tulsa, Oklahoma, seeks a Director of Utilization Management to provide strategic and operational leadership for the health plan's Physical Health Utilization Management department reporting to the Chief Medical Officer.

You will lead a large team, drive data-driven strategies to improve clinical appropriateness, affordability, efficiency, and quality, and ensure compliance with regulatory standards. This role requires RN licensure and senior leadership experience.