Director of Medical Management

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The Director of Care Navigation & Medical Cost Management leads a multidisciplinary team of Navigators focused on improving member outcomes and reducing healthcare costs. This role drives strategic initiatives that address high-cost conditions (including diabetes and end-stage renal disease), reduce emergency room utilization, and enhance care coordination across the network. The Director collaborates with internal departments, providers, vendors, and health centers to implement data-driven, member-centered programs that support value-based care and health equity.

Essential Job Functions And Duties

• Lead and manage Health Navigator and Nurse Navigator teams to ensure effective care coordination and cost mitigation strategies.
• Develop and oversee programs targeting high-cost members, providers, and chronic conditions, with a focus on diabetes and ESRD.
• Collaborate with utilization management (UM) vendors and internal teams to optimize site-of-care decisions and prior authorization protocols.
• Partner with Claims, Analytics, and Healthcare Delivery teams to analyze medical and pharmacy claims data and identify actionable cost drivers.
• Support network management efforts by guiding members to in-network providers and reducing unnecessary emergency room visits.
• Work with health centers, providers, and community organizations to promote coordinated care and reduce healthcare disparities.
• Monitor program effectiveness through ROI metrics, member outcomes, and cost trend analyses.
• Ensure compliance with HIPAA, payer guidelines, and internal policies.
• Provide strategic input on benefit design and policy development based on cost and utilization trends.
• Communicate program goals, outcomes, and opportunities to executive leadership and key stakeholders.
• Plans, analyzes, and evaluates programs and services, operational needs, and fiscal constraints
• Supervises, leads, and delegates work and coaches, mentors, develops employees
• Analyzes problems, identifies, and develops alternative solutions, projects consequences of proposed actions, and implements recommendation/solutions
• Recommends hires and promotions, directs, and evaluates employment decisions for all assigned positions
• Assists with developing and coordinating policies and procedures
• Responsible for the oversight of continued employee training requirements, safety, and quality initiatives
  
  

Essential Qualifications

• 7 ~ 10 years of SELECT DIRECT OR RELATED experience minimum
• Bachelor’s Degree in Nursing (BSN) required; Master’s Degree in Healthcare Administration (MHA), Public Health (MPH), or Business Administration (MBA) preferred.
• Active Registered Nurse (RN) license required
• Minimum of 7 years of experience in medical cost management, care coordination, or utilization management.
• Strong knowledge of managed care principles, value-based care, and healthcare cost-containment strategies.
• Understanding of self-funded health plans.
• Experience with chronic disease management programs, especially diabetes and ESRD.
• Proficiency in healthcare analytics platforms and data interpretation.
• Excellent leadership, communication, and strategic planning skills.
• Familiarity with EHR systems, payer platforms, and UM software.
• Experience working with union populations or in a labor health fund environment is a plus.
• Bilingual language skills preferred.
• Remote position with occasional travel for provider meetings, member outreach, and strategic planning sessions.
  
  

Salary range for this position: Salary $156,600 - $195,900. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday thru Friday, 7.5 hours per day (37.5 hours per week) as a flexible hybrid employee.

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Short- & Long-term Disability, Pension, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).