Utilization Management Senior Director (Healthcare)

TL;DR

Utilization Management Senior Director (Healthcare): Leading the transformation of complex regulatory guidance into scalable business processes for a healthcare provider with an accent on process optimization and regulatory translation. Focus on driving cross-functional alignment, improving decision accuracy, and utilizing AI-enabled tools to refine the medical care journey.

Location: Fully Remote (Must be located within the 50 U.S. states). Standard working hours are in Eastern Timezone.

Salary: $182,000–$278,000 annually

Company

An all-in-one healthcare company combining compassion, insurance, clinical care, and technology to improve the health and well-being of older Americans.

What you will do

• Identify and execute process improvements, workflow optimization, and technology enhancements across the UM department.
• Translate regulatory guidance (e.g., NCDs, LCDs, Medicare Managed Care Manual) into compliant operational workflows.
• Drive alignment and change across cross-functional stakeholders, including Clinical, Product, Engineering, and Network teams.
• Build credibility and manage relationships with internal teams and external vendors/provider partners.
• Utilize data-driven insights and AI-enabled tools to continuously refine the medical care journey.

Requirements

• Must be based in the United States.
• 10+ years of professional experience in healthcare operations or a related field.
• Proven track record of transforming operational challenges into scalable business processes in fast-paced environments.
• Deep analytical ability to master complex regulatory guidance and incorporate it into daily operations.
• Strong understanding of Utilization Management processes and the medical necessity review lifecycle.
• Bachelor’s degree is required.

Nice to have

• Prior experience in Medicare Advantage UM operations or Risk Adjustment.
• MBA or advanced degree in health administration or finance.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.
• Generous paid time off and parental leave program.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• 401K program.