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RN Director of Utilization Management

Boston, MA · Healthcare
RN Director of Utilization Management – Health Plan
Boston, MA (west suburb, near Cambridge)
$$$ Generous Relocation Package available to attract top-talent from around the Nation! $$$

RN Director of Utilization Management Job Summary:

  • The Director of Inpatient Utilization Management is responsible for directing, leading and modifying the business processes and operations for all levels of inpatient management for Commercial and Public Plans lines of business.
  • Oversees and leads medical management activities related to inpatient utilization review and discharge planning for acute inpatient, LTAC, rehabilitation and skilled nursing services.
  • Ensures initiatives are on schedule and within budget, and guides strategy, policies and protocols in accordance with organizational strategy.
  • Guarantees collaboration and coordination with enterprise or divisional based behavioral health and / or case management leaders and programs.
  • Assumes a leadership role with internal and external customers to achieve optimal clinical and resource outcomes.
  • Strategically develop and effectively deploy solutions in support of corporate and division specific goals.
  • Collaborates with division and enterprise business and medical leadership in order to drive clinical and/or operational initiatives.
RN Director of Utilization Management Background

  • Valid, unrestricted state Registered Nurse (R.N.) license, and a Bachelor’s Degree in Nursing (BSN) or related field; Master’s degree is a plus.
  • Certified in Utilization Management (CPUM/CPUR/CPHM) is a plus.
  • Around 5 years’ clinical nursing experience in a high acuity setting.
  • Roughly 7-10 years’ experience in Utilization Review/ Utilization Management for a Managed Care Organization (Health Plan, IPA, HMO, TPA, etc).
  • At least 8 years previous management experience, including hiring and supervising at least 50 direct/indirect reports.
  • Requires experience with operations of Commercial (fully funded and self-funded), Exchange, Medicaid and Medicare products.
  • Must have a proven ability to achieve goals and deliver "bottom line" results.
  • Excellent working knowledge of managed care operations and business processes is essential, with proven competence in directing compliance with CMS and NCQA, URAC or DOI requirements.
  • Strong computer proficiency (MS Office) and typing skills are necessary.
  • Skilled in influencing, leading and directing individuals in multiple functional areas; proven ability to successfully lead staff is required.
  • Able to transform assignments from high-level objectives into independently established detailed goals.
  • Excellent verbal and written communication skills, as well as exceptional critical thinking skills.


480.646.3275 (CALL – TEXT – FAX)
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