What are the responsibilities and job description for the Director of Utilization Management position at Guidant MSO?
Company Description
Guidant MSO is a dynamic and forward-thinking organization dedicated to delivering high-quality management services in the healthcare sector. Leveraging industry expertise, we provide innovative solutions that improve operational efficiency and patient care outcomes. Guided by a commitment to excellence, our team collaborates to support healthcare providers in optimizing resources and achieving their goals.
Position Details:
Director of Utilization Management
Location: Remote/Hybrid
Department: MSO Operations - Utilization Management
Reports to: Vice President of MSO Operations
Pay Range: $140,000 - $170,000
**Salary is comensurate on a combination of skill set, education, and field experience.
About the role
Guidant MSO is seeking an experienced and strategic Director of Utilization Management (UM) to lead our Utilization Management and Case Management (CM) functions, as well as oversee our Quality Improvement Department (QI). This leader will ensure our medical management operations are efficient, compliant, and aligned with regulatory, contractual, and quality requirements while supporting high-quality care for our patients.
Key responsibilities
- Provide overall direction and oversight for concurrent review, prior authorization, and case
management activities to support appropriate, timely, and cost‑effective use of health care
resources.
- Develop, implement, and maintain UM and CM strategies, policies, and protocols in line with
regulatory requirements and industry best practices.
- Lead, mentor, and develop UM and CM leaders and staff; set clear expectations and foster a
high‑performance, accountable culture.
- Define, monitor, and enforce key performance indicators related to quality, productivity, and
turnaround times.
- Stay current on CMS, DMHC, health plan, and other regulatory guidelines and collaborate with
leadership to ensure compliance and operational efficiency.
- Participate in and support compliance audits, including data analysis, root cause analysis, and
corrective action planning.
- Partner with health plans, providers, and internal stakeholders on quality improvement initiatives and
UM/CM program enhancements.
- Lead or participate in UM Committee and Interdisciplinary Care Team (ICT) meetings as needed.
- Analyze and report on utilization trends, patterns, and resource allocation; collaborate with medical
directors and executive leadership to drive appropriate utilization of services.
- Align UM and CM strategies with payment integrity, policy, and network development activities to
optimize quality and cost of care.
- Oversee strategic projects and operational initiatives within the UM and CM departments.
- Ensure consistent and timely inter‑rater reliability reviews for UM staff at least annually.
Qualifications
Education (required):
- Bachelor’s degree in Nursing **or**
- Master’s degree in Health Care Administration or Business Administration.
Education (preferred):
- Master’s degree in Nursing.
- Case Management or Utilization Management certification.
Experience (required):
- 10 years’ experience in a health plan, IPA/medical group, MSO, or hospital in a utilization or case
management capacity.
- 6 years’ management experience in a health plan, IPA/medical group, MSO, or hospital setting.
- Experience working within a health plan or similar health care organizational structure.
- 5 years’ experience in a health care compliance capacity.
Experience (preferred):
- Contracting and/or claims experience.
Skills and competencies
- Deep understanding of UM/CM regulations, standards, and best practices.
- Strong knowledge of medical terminology, ICD‑10 and CPT coding, contract and DOFR
interpretation, and reimbursement methodologies.
- Proven ability to use data analytics and reporting to drive decisions and performance improvement.
- Excellent written and verbal communication skills, with the ability to collaborate effectively across
disciplines and represent the organization to external stakeholders.
- Demonstrated leadership, critical thinking, and problem‑solving skills in a fast‑paced and evolving
environment.
- Proficiency with Microsoft Office (Outlook, Word, Excel, PowerPoint, Visio).
- Experience with budget planning and efficient resource allocation.
Work environment
This is a full‑time, exempt position in an office setting that requires frequent computer use and collaboration with internal and external partners.
How to apply
Please submit your resume and a brief cover letter outlining your relevant Utilization Management and leadership experience via LinkedIn Easy Apply or directly to our recruiting team.
Salary : $140,000 - $170,000