Senior Director of Medical Review

Overview

We are looking for a SENIOR DIRECTOR OF MEDICAL REVIEW who can help shape our vision and support our mission. Here is what the position will look like.

• Provides strategic direction and oversees the management and maintenance of multiple department deliverables striving for operational excellence (productivity, quality, SLAs, customer experience of services provided, etc.).
• Builds high performing teams with vision, leadership, goals and metrics. Serves as a role model for team members; takes action and inspires team members to embrace and implement culture initiatives.
• Provides awareness to department leaders and staff how their work impacts other departments, programs and the enterprise. Encourages collaboration and holds team members accountable for achieving outstanding results.
• Responsible for all management functions including hiring, training, planning and directing work, coaching and staff development, managing and evaluating performance, recognizing and rewarding employees, corrective action procedures and practices, addressing complaints and resolving problems.
• Develops and manages multiple department budgets.
• Works closely with Directors across the organization to make tactical and operational decisions that advance company strategies and goals and collaborates to deliver on company-wide deliverables/requirements.
• Oversees/leads projects and continuous improvement initiatives across multiple departments and/or cross-functional teams.
• Oversee the development and implementation of multiple department policies and procedures to ensure compliance with federal, state, local and company policies, rules and regulations.

• Own the end-to-end vision, strategy, and execution for Utilization Management (UM) and Pharmacy across all lines of business, ensuring alignment with organizational mission, values, and strategic imperatives.
• Direct, develop, and evaluate the UM program annually ensuring success through medical review and prior authorization, behavioral health management, clinical intake, and inpatient and outpatient review.
• Directs and develops specialty programs to support and ensure success of the UM program, inclusive of innovative programs that emphasize and utilize hospital collaborative work relationships, and internal and external partnerships; ensures compliance and administration of utilization policies through cost effective management of UM operations.
• Partner with leaders across the enterprise to design and evolve utilization management and pharmacy strategies that support competitive benefit design, affordability, and member and provider experience across all lines of business.
• Provide clinical and financial oversight of pharmacy team, pharmacy benefits, and pharmacy benefit manager (PBM), including contract management and value-based care incentives.
• Develops, secures approval and monitors and reports on area operating budget; forecasts spending levels, staffing requirements and resource needs for area.
• Serve as the organization’s go-to resource on state, federal, and NCQA requirements, shaping UM/Pharmacy policies, keeping the organization ahead of regulatory changes, and leading audits (EPSDT, MHPAEA, SUD Residential Review, and other compliance reviews).
• Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees to inform strategic planning and performance management.
• Turn utilization and financial data into actionable insights that drive performance improvements, reduce unnecessary costs, and support quality outcomes.
• Facilitates educational training for clinical staff on issues related to utilization management processes, compliance updates and emerging best practices.
• Lead the development of market-competitive UM and pharmacy approaches—including prior authorization optimization, delegation, automation, and provider-friendly practices—by monitoring competitor benchmarks, regulatory expectations, and emerging best practices.

• Education: Master’s degree in behavioral health field, nursing, health services administration, or other related health…