Director, Utilization Review

About Company:

We’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.

Read more here: https://ow.ly/YQ1C50WuRH1

This certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

Our benefits include:

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.

• Generous PTO – A robust paid time off policy to support work-life balance.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

At Bradford Health Services, we don’t just invest in our patients—we invest in our people.

About the Role:

The Director of Utilization Review plays a critical leadership role in overseeing the utilization management processes to ensure the delivery of high-quality, cost-effective healthcare services. This position is responsible for developing and implementing strategies that optimize resource use while maintaining compliance with regulatory standards and payer requirements. The Director leads a multidisciplinary team to evaluate clinical appropriateness, manage case reviews, and support care coordination efforts across the organization. By leveraging data analytics and clinical expertise, this role drives continuous improvement initiatives that enhance patient outcomes and operational efficiency. Ultimately, the Director serves as a key liaison between clinical staff, payers, and leadership to align utilization review activities with organizational goals and healthcare best practices.

Minimum Qualifications:

• Bachelor’s degree in Nursing, Health Administration, or a related healthcare field.
• Minimum of 5 years of progressive experience in utilization review, case management, or healthcare operations.
• Strong knowledge of healthcare regulations, payer policies, and accreditation standards related to utilization review.
• Demonstrated ability to analyze clinical data and implement process improvements.

Preferred Qualifications:

• Master’s degree in Nursing, Healthcare Administration, Public Health, or a related field.
• Leadership experience managing clinical teams in a utilization management or related environment.
• Certification in Case Management (CCM), Utilization Review (URAC), or related professional credentials.
• Experience working within managed care organizations or health insurance companies.
• Proficiency with healthcare data analytics tools and electronic health record (EHR) systems.
• Familiarity with value-based care models and population health management.

Responsibilities:

• Lead and manage the utilization review department, ensuring timely and accurate clinical reviews in accordance with regulatory and accreditation standards.
• Develop and implement policies, procedures, and protocols to standardize utilization management practices across the organization.
• Collaborate with clinical teams, case managers, and external payers to facilitate appropriate care delivery and resolve utilization-related issues.
• Analyze utilization data and trends to identify opportunities for process improvements and cost containment.
• Provide training, mentorship, and performance evaluations for utilization review staff to maintain high levels of clinical competency and compliance.
• Ensure adherence to all federal, state, and payer regulations related to utilization review and healthcare compliance.
• Serve as a subject matter expert on utilization management during audits, accreditation surveys, and internal reviews.
• Partner with quality improvement and risk management teams to integrate utilization review findings into broader organizational initiatives.

Skills:

The Director of Utilization Review utilizes strong clinical knowledge and leadership skills daily to guide the team in making informed decisions about patient care appropriateness and resource allocation. Analytical skills are essential for interpreting utilization data and identifying trends that inform strategic improvements. Effective communication and collaboration skills enable the Director to work closely with clinical staff, payers, and executive leadership to align utilization review processes with organizational objectives. Regulatory expertise ensures that all activities comply with evolving healthcare laws and payer requirements, minimizing risk and enhancing quality. Additionally, proficiency in healthcare technology and data systems supports efficient workflow management and accurate reporting.