Director Utilization Management MedStar Family Choice

MedStar Health; Washington (District of Columbia); On-site; USD 121,000 - 238,000; Full time

Job summary

MedStar Health in Washington, DC, seeks a Director of Utilization Management to lead the centralized UM function across plans, ensuring evidence-based utilization and regulatory compliance while driving cost-effective, high-quality care. You will standardize workflows, oversee prior authorization and reviews, partner with Case Management and Pharmacy, and provide executive reporting to senior leadership.

This role requires extensive managed care and Medicaid experience, RN licensure, and strong

Qualifications

• Bachelor's degree in Nursing, Social Work or related healthcare field is required.
• Master's degree preferred (Nursing, Public Health, Healthcare Admin or related).
• Experience in managed care and utilization management leadership required.
• Knowledge of Medicaid, CMS, NCQA requirements advantageous.

Responsibilities

• Leads enterprise-wide utilization management strategy across all health plans.
• Standardizes UM policies, workflows, and clinical criteria application across markets.
• Oversees prior authorization, concurrent, and retrospective reviews for timely, compliant determinations.

Skills

Strategic leadership

Healthcare analytics

Regulatory compliance

Change management

Executive communication

Education

Bachelor's degree in Nursing or related healthcare field

Master's degree in Nursing / MPH / MHA / MBA or related field

Job description

General Summary of Position

The Director of Utilization Management (UM) provides strategic and operational leadership for the health plan's centralized utilization management function across both plans. This role ensures appropriate evidence-based utilization of services while maintaining regulatory compliance improving quality outcomes and driving cost-effective delivery. Under a centralized clinical operation model the Director aligns UM process across plans standardizes workflows optimizes technology and integrates closely with Case Management Pharmacy Quality and Provider Relations to support enterprise-wide performance goals.

About The Job

The Director of Utilization Management (UM) provides strategic and operational leadership for the health plan's centralized utilization management function across both plans. This role ensures appropriate evidence-based utilization of services while maintaining regulatory compliance improving quality outcomes and driving cost-effective delivery. Under a centralized clinical operation model the Director aligns UM process across plans standardizes workflows optimizes technology and integrates closely with Case Management Pharmacy Quality and Provider Relations to support enterprise-wide performance goals.

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.