Utilization Management Director

Position: Utilization Management Director

Duration: 6 month Contract to Hire

Location: Remote

Position Summary:

The Utilization Review Director – Prior Authorization leads the strategy and operations of the prior authorization function for a health plan, ensuring timely, compliant, and evidence-based medical necessity reviews. This role drives efficiency, oversees clinical and non-clinical review teams, and partners cross-functionally to support utilization management goals across all lines of business.

Key Responsibilities:

-Lead daily operations of the prior authorization unit, ensuring compliance with NCQA, CMS, and state regulatory standards.

-Oversee clinical decision-making processes using evidence-based guidelines (e.g., GuidingCare, MCG, InterQual).

-Manage and mentor review teams, including RNs and support staff, to meet performance and turnaround targets.