Strategic Director, Utilization Management & Clinical Ops

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

Job summary

MedStar Health seeks a Director of Utilization Management to provide strategic and operational leadership for centralized UM across the health plan. The role ensures evidence-based utilization, regulatory compliance, and alignment with enterprise performance goals.

The position collaborates with Case Management, Pharmacy, Quality and Provider Relations to standardize workflows, optimize technology, and drive improvements in cost-effective care delivery.

Qualifications

• Bachelor’s degree in Nursing, Social Work or related healthcare field required.
• Master’s degree in Nursing (MSN), Public Health (MPH), Healthcare Administration (MHA) or Business Administration (MBA) preferred.
• RN – State Licensure required at hire (MD/DC).

Responsibilities

• Lead enterprise utilization management strategy across all health plans.
• Standardize UM policies and workflows for consistency.
• Oversee prior authorization, concurrent and retrospective review processes.
• Ensure compliance with Medicaid, NCQA, CMS and contracts.

Skills

Medicaid/NCQA knowledge

Data analytics

Change management

Executive communication

Education

Bachelor’s degree in Nursing, Social Work or related field

Master’s degree in Nursing, Public Health, Healthcare Administration or MBA

RN licensure

Tools

InterQual

Job description

MedStar Health seeks a Director of Utilization Management to provide strategic and operational leadership for centralized UM across the health plan. The role ensures evidence-based utilization, regulatory compliance, and alignment with enterprise performance goals.

The position collaborates with Case Management, Pharmacy, Quality and Provider Relations to standardize workflows, optimize technology, and drive improvements in cost-effective care delivery.