Director, Utilization Management

Job Description

Title: Director, Utilization Management
Department: Clinical Operations
Reports To: Vice President, Clinical Operations
FLSA Status: Exempt
Location: Hybrid, 2 days in office (Tuesday and Thursday in office 1460 Broadway New York, NY), 3 days Remote

Position Summary

The Manager, Utilization Management (UM) provides strategic and operational leadership for Antidote Health’s UM programs. This role oversees authorization processes, medical necessity reviews, concurrent and retrospective review, and appeals/grievances. The Director ensures compliance with NCQA, CMS, and state regulations while balancing clinical appropriateness, operational efficiency, and member/provider satisfaction. The position is also responsible for vendor oversight of delegated UM entities, ensuring performance, compliance, and quality outcomes.

Essential Duties and Responsibilities

Leadership & Staff Development

• Supervise and evaluate UM supervisors and nursing staff.
• Provide coaching, feedback, and recognition to foster accountability, engagement, and retention.
• Ensure staff maintain current clinical competencies and meet NCQA/regulatory training requirements.
• Maintain staffing ratios that support timely review turnaround and regulatory compliance.

Operations, Compliance & NCQA

• Direct day-to-day UM operations, including prior authorization, concurrent review, retrospective review, and appeals/grievances.
• Ensure all UM decisions follow evidence-based criteria (e.g., MCG) and regulatory requirements.
• Oversee documentation, workflows, and reporting to align with NCQA standards and state/federal regulations.
• Conduct audits, identify deficiencies, and implement corrective actions to maintain continuous readiness.
• Develop and update UM policies and procedures to ensure compliance and operational efficiency.

Vendor Collaboration

• Act as primary liaison for delegated UM vendors.
• Monitor vendor performance and compliance with contractual and NCQA obligations.
• Escalate deficiencies, enforce corrective action plans, and track resolution.
• Collaborate with vendors to streamline workflows and improve member/provider experience.
• Provide training and support as appropriate to delegated partners.

Data Analytics & Reporting

• Oversee preparation and analysis of UM metrics (e.g., turnaround times, denial rates, appeals, overturn rates, concurrent review outcomes).
• Apply advanced Excel and reporting tools to analyze large datasets and identify trends.
• Translate data into actionable strategies to improve compliance, efficiency, and provider/member satisfaction.
• Provide accurate, timely reports to leadership and oversight committees.

Collaboration & Integration

• Partner with internal teams (Case Management, Medical Directors, Quality, Provider Relations, Network) to align UM processes with organizational goals.
• Support initiatives that improve care quality, reduce unnecessary utilization, and enhance member/provider engagement.
• Collaborate across departments to ensure continuity of care and effective transitions across settings.

Supervisory Responsibilities

• Direct supervision of UM supervisors and staff.
• Oversight of delegated UM vendor staff in collaboration with vendor leadership.

Qualifications

Required

• Bachelor’s in nursing (required).
• Active, unrestricted RN license.
• Minimum 5 years of managed healthcare experience in utilization management.
• Supervisory/management experience in UM within a managed care organization.
• Demonstrated expertise with NCQA UM standards, CMS requirements, and state regulations.
• Advanced proficiency in Excel and data analytics.
• Strong leadership, communication, and interpersonal skills.

Ideal Candidate‍

The ideal candidate is a nurse leader with advanced knowledge of NCQA UM standards, clinical criteria (MCG/InterQual), vendor oversight, and data analytics. They have a proven track record of:

• Leading UM programs through audits and accreditation with continuous readiness.
• Driving improvements in turnaround times, appeals outcomes, and compliance rates.
• Holding delegated UM vendors accountable for performance and compliance.
• Mentoring supervisors and staff to achieve high engagement and productivity.
• Translating data into actionable strategies that improve outcomes and operational efficiency.
• Leading through collaboration and influence to align UM with broader organizational goals.