Senior Director, Health Plan Utilization Management

Role Overview

• Provide strategic and operational leadership for all utilization management functions across the organization.
• Ensure clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations while supporting high-quality member outcomes and provider collaboration.
• Partner closely with Operations, Network Management, Quality, Compliance, and Finance to align utilization management strategy with organizational goals.
• Oversee multiple teams performing utilization management functions.
• Develop, implement, and evaluate formal educational activities and follow up on issues identified through educational activities.
• Ensure DHMP can provide documentation of compliance with contractual and regulatory requirements prior to audit.

Requirements

• Master's degree required
• Graduation from an accredited educational program for Nursing or Physician’s Assistants required
• Seven years of experience in administration in managed care, health plan administration or healthcare provider organizations required
• Minimum of five years of supervisory and management experience required
• 1-3 years Health Plan or healthcare experience with various lines of business including Medicare, Medicaid, CHP, Exchange and/or Commercial Plans required
• 1-3 years Experience in managing vendors required
• Knowledge of regulatory and accreditation standards for health plan or healthcare operations required
• Strong program development, analysis, and evaluation skills required
• Strong knowledge and experience in utilization principles, concepts, and strategies preferred

Benefits

• Outstanding benefits including up to 27 paid days off per year
• Immediate retirement plan employer contribution up to 9.5%
• Generous medical plans
• Free RTD EcoPass (public transportation)
• On-site employee fitness center and wellness classes
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education & development opportunities including career pathways and coaching
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer