Strategic Director, Enterprise Utilization Management

MedStar Health

Washington (District of Columbia)

On-site

USD 121,000 - 238,000

Full time

4 days ago

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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.