Director, Utilization Management Operations

CareSource; United States; On-site; USD 136,000 - 237,000; Full time

Job summary

CareSource seeks a Director of Utilization Management Operations to support the UM Department in advancing initiatives, program development, and contract compliance. The role emphasizes leadership across clinical teams, regulatory alignment, and data-driven outcomes.

The position requires extensive experience in medical management operations, with preferred UM background and knowledge of Medicaid/Medicare/Managed Care, plus strong communication and project leadership skills.

Qualifications

• Bachelor's degree or equivalent years of relevant work experience is required.
• Master's degree in Health Care Administration and two years of post-degree professional experience is preferred.
• Minimum of five (5) years medical management operations, leadership, program, or management experience is required.
• Minimum of one (1) year Utilization Management experience preferred.
• Experience implementing programs with focus on integration is preferred.
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred.

Responsibilities

• Manages and prioritizes UM and related projects, ensuring timeliness and completion.
• Gathers and prioritizes business requirements for departmental requests including regulatory reporting.
• Monitors performance across programs to identify improvement opportunities and standardize evidence-based practices.
• Leads collaboration with clinical teams and stakeholders for coordination and communication.
• Supports readiness activities for implementation of new business and programs.
• Develops program documents and operational workflows.
• Engages stakeholders to ensure alignment across the organization.
• Recruits, develops, and leads key staff.

Skills

Visio

Word

Excel

PowerPoint

Project

Communication

Independent work

Organization

Time management

Analysis

Problem solving

Project management

Relationship building

Training & change agent

Critical thinking

Health services knowledge

Education

Bachelor's degree or equivalent

Master's degree in Health Care Administration

Job description

Job Summary:

The Director, Utilization Management Operations assists the UM Department with all open projects and progress towards company and department initiatives including program descriptions, evaluations, policies, procedures, new business requirements, contract compliance and execution, and all related activities

Essential Functions:

• Manages and prioritizes UM and related projects, and ensures timeliness and adherence to completion
• Responsible for gathering and prioritization of business requirements for departmental requests including regulatory reporting
• Monitors performance across programs to identify improvement opportunities, leverage best practice and knowledge sharing for the purpose of improving outcomes through the standardization of evidence‑based practices
• Leads collaboration with all clinical teams and other stakeholders to ensure coordination and communication
• Assists with the monitoring of legislative/governmental activities with the goal of coordinating the full integration of clinical services, identifying opportunities and issues
• Supports the ongoing, data‑driven approach to improve outcomes and experiences for members
• Supports and leads readiness activities for implementation of new business and programs
• Develops program documents and operational workflows
• Engages stakeholders to ensure alignment across the organization
• Adds services and processes related to the development of new lines of business as required
• Recruits, develops, and leads key staff
• Perform any other job‑related instructions, as requested

Education and Experience:

• Bachelor's Degree or equivalent years of relevant work experience is required
• Master's degree in Health Care Administration and two years of post‑degree professional experience is preferred
• Minimum of five (5) years medical management operations, leadership, program, or management experience is required
• Minimum of one (1) year Utilization Management experience preferred
• Experience implementing programs with focus on integration is preferred
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred

Competencies, Knowledge and Skills:

• Strong Knowledge of Visio, Microsoft Word, Excel, PowerPoint and Project
• Strong communication Skills; written and verbal
• Ability to work independently and within a team environment
• Strong organizational, time management, analysis, and problem‑solving skills
• Ability to manage a project from start to finish
• Strong relationship building skills and leadership qualities
• Training and teaching skills/change agent
• Ability to think critically and lead with strategy
• Comprehensive knowledge base crossing all areas within the Health Services Areas including: Behavioral Health, Case Management, Utilization Management, Integration and Pharmacy

Licensure and Certification:

Current, unrestricted RN licensure is preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time Some travel may be required to fulfill the duties of the role

Compensation Range:

$135,600.00 - $237,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well‑being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SW2 Brand=CareSource

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference‑makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer‑centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we're looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.