Director, Utilization Management - Transformational Clinical Ops

Healthfirst; Layton (UT); On-site; USD 140,000 - 210,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401(k) contributions

Job summary

Healthfirst seeks a Director of Utilization Management to lead clinical operations, delivering strategic and operational oversight for UM teams, including prior authorizations, concurrent reviews, and service requests, ensuring medically necessary, cost-efficient care in line with CMS and payer requirements.

This transformational leader will shape policies, monitor performance metrics, and drive modernization within the UM program, collaborating with Care Management, Clinical Eligibility,

Qualifications

• Bachelor’s degree in healthcare, business, or a related field.
• Progressive healthcare leadership experience.
• Experience with Medicare/Medicaid or MLTC.

Responsibilities

• Provide strategic direction to UM leaders and teams for prior authorizations, concurrent reviews, and service requests.
• Develop policies aligning with payer guidelines and regulatory requirements.
• Monitor metrics and utilization trends to drive improvements.
• Collaborate with other operations leaders and technology/data teams.

Skills

Healthcare leadership

Regulatory compliance

Healthcare management

Change management

Data analysis

Communication

Strategic thinking

Education

Bachelor’s degree in healthcare or related field

Master’s degree preferred

Tools

Milliman Care Guidelines (MCG)

Job description

Healthfirst seeks a Director of Utilization Management to lead clinical operations, delivering strategic and operational oversight for UM teams, including prior authorizations, concurrent reviews, and service requests, ensuring medically necessary, cost-efficient care in line with CMS and payer requirements.

This transformational leader will shape policies, monitor performance metrics, and drive modernization within the UM program, collaborating with Care Management, Clinical Eligibility,