Senior Director, Utilization Management & Health Plan Strategy

Nearterm Corporation; Colorado; On-site; USD 150,000 - 190,000; Full time

Job summary

Nearterm Corporation in Colorado is seeking a Proven Utilization Management & Health Plan Leader to provide strategic and operational leadership across the utilization management functions.

The role requires coordinating with the health system and medical plan, ensuring clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations, and collaborating closely with providers to optimize member outcomes.

Qualifications

• Senior leader for the Health System and Medical Plan with responsibility for providing strategic and operational leadership for all utilization management functions across the organization.
• Regulatory compliance requirements for each line of business.
• Ensuring clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations while supporting high-quality member outcomes and provider collaboration.
• Senior Director partners closely with Operations, Network Management, Quality, Compliance, and Finance to align utilization management strategy with organizational goals.

Responsibilities

• Oversees multiple teams performing utilization management work.
• Reports to the Chief Medical Officer and collaborates closely with them to develop, update and implement the Utilization Management vision and strategy.

Job description

Nearterm Corporation in Colorado is seeking a Proven Utilization Management & Health Plan Leader to provide strategic and operational leadership across the utilization management functions.

The role requires coordinating with the health system and medical plan, ensuring clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations, and collaborating closely with providers to optimize member outcomes.