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Healthfirst Logo Healthfirst · IT - Administration

Director, Utilization Management

United States, New York Employment contract 127500.00 - 236555.00 USD / Year · Job Posted May 16, 2026
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Job Description

The Director of Utilization Management is a transformational clinical operations leader responsible for delivering strategic and operational oversight for Utilization Management (UM) teams. This high-impact forward-thinking leader drives clinical and operational excellence across all UM functions, including prior authorizations, concurrent reviews, and service requests while ensuring the delivery of medically necessary, cost-effective, and high-quality care in full compliance with CMS, NYSDOH, and contractual requirements.. The Director will bring deep operations leadership experience, executive presence, strong change management capability, and a modernization mindset with the ability to lead transformation initiatives in complex healthcare environments. This dynamic leader will leverage data-driven decision making to drive process improvement through workflow automation, AI-enabled decision support, and streamlined UM operations. that helps shape the future of utilization management.

Job Responsibility

  • Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests
  • Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching
  • Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements
  • Deliver on Healthfirst’s Mission by ensuring optimum quality of member care in a cost-effective manner
  • Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
  • Develop and monitor appropriate metrics to maintain and improve department performance
  • Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement
  • Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology
  • Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives
  • Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions
  • Partner with technology and data teams to refine data governance and reporting, inform AI use cases, and performance monitoring frameworks
  • Support organizational change management for UM modernization efforts, fostering engagement, communication, and adoption of new technologies or processes
  • Advocate and actively participate as the clinical voice on various clinical committees and other clinical policy workgroups
  • Additional duties as assigned

Requirements

  • Bachelor’s degree in healthcare, business, or a related field from an accredited institution or equivalent work experience
  • Progressive leadership experience in healthcare management including work experience in a mid-senior management role
  • Work experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP).
  • Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
  • Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS.
  • Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions.
  • Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.

Nice to have

  • Master’s degree in health-related area
  • Proven ability to lead complex teams and manage interdisciplinary care models in a health plan or integrated delivery system
  • Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.
  • Strategic thinker with strong operational discipline and capacity for executive-level decision-making
  • Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC.
  • Strong computer skills, including, but not limited to word processing, spreadsheets, and databases.
  • Strategic thinker with strong operational discipline and capacity for executive-level decision-making

What we offer

  • medical, dental and vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions
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