Director of Utilization Management

About Lucent Health

Lucent Health combines top-tier claims management with a compassionate, human-focused, data-driven care management solution. This approach helps self-insured employers provide care management that enables health plan participants to make smarter, cost-saving healthcare decisions. Continuous data analytics offer ongoing insights, ensuring participants receive the right care, at the right cost, at the right time. Join us as we build a company that aims to be a better health benefits partner for self-insured employers.

Company Culture

We believe that the success of Lucent Health relies on having employees who are honest, ethical and hardworking. These values are the foundation of Lucent Health.

Honest

• Transparent Communication: be open and clear in all interactions without withholding crucial information
• Integrity: ensure accuracy in reporting, work outputs and any tasks assigned
• Truthfulness: provide honest feedback and report any issues or challenges as they arise
• Trustworthiness: build and maintain trust by consistently demonstrating reliable behavior

Ethical

• Fair Decision Making: ensure all actions and decisions respect company policies and values
• Accountability: own up to mistakes and take responsibility for rectifying them
• Respect: treat colleagues, clients and partners with fairness and dignity
• Confidentiality: safeguard sensitive information and avoid conflicts of interest

Hardworking

• Consistency: meet or exceed deadlines, maintaining high productivity levels
• Proactiveness: take initiative to tackle challenges without waiting to be asked
• Willingness: voluntarily offer to assist in additional projects or tasks when needed
• Adaptability: work efficiently under pressure or in changing environments

Summary

The Director of Utilization Management (UM) and Clinical Quality is responsible for the strategic and operational leadership of the Utilization Management department. This includes ensuring compliance with regulatory and accreditation standards, driving clinical quality improvement, and maintaining optimal performance of UM operations, including nurse and physician reviews, appeals management, utilization-related metrics, and phone and queue management for the team. The Director ensures that utilization practices support appropriate, cost-effective, and high-quality care for members while achieving contractual, operational, and regulatory expectations. The Director of UM and Clinical Quality reports to the Vice President of Clinical Operations.

Responsibilities

Utilization Management Oversight

• Lead and oversee all daily UM activities, including prospective, concurrent, and retrospective reviews, as well as inbound calls, faxes, and web submissions of authorizations.
• Ensure timely completion of medical necessity reviews and compliance with internal turnaround time (TAT) standards and external regulatory requirements.
• Manage physician review processes in coordination with Medical Directors and external physician reviewers.
• Provide oversight and guidance for complex cases, escalations, and interdepartmental collaboration.
• Maintain prior authorization requirements with clarity for providers.

Appeals and Grievance Management

• Oversee the clinical review of appeals and ensure compliance with regulatory and contractual timelines.
• Collaborate with legal, compliance, and quality teams to ensure consistency in appeal determinations and member/provider communication.

Clinical Quality & Utilization Metrics

• Monitor, analyze, and report on UM performance indicators, including denial rates, approval trends, appeals overturns, and TAT compliance.
• Identify opportunities for improvement and lead initiatives to optimize clinical decision-making, reduce over- and under-utilization, and improve quality of care.
• Present regular reports and dashboards to senior leadership, clients, and quality committees.

Regulatory & Accreditation Compliance

• Ensure ongoing compliance with state Utilization Review (UR) licensing requirements across all applicable jurisdictions.
• Lead efforts to maintain URAC (or other applicable) accreditation, including oversight of audits, policies/procedures, and performance improvement plans.
• Stay current on federal and state regulations impacting utilization management and ensure internal alignment.

Leadership & Team Development

• Lead and mentor a multidisciplinary team including nurses, UM coordinators, physician advisors, and appeal reviewers.
• Develop staffing models, training programs, and performance management processes to ensure clinical and operational excellence.
• Foster a culture of accountability, collaboration, and continuous improvement.

Interdepartmental Collaboration

• Collaborate with Medical Management, Case Management, Quality Improvement, Claims, Provider Relations, and Compliance to ensure cohesive operations and member-centered care.
• Serve as a key clinical leader in client meetings, audits, and vendor partnerships related to UM and clinical quality.

Qualifications

• Registered Nurse with a minimum of 5 years of recent clinical nursing experience.
• Minimum of 5 years in utilization management, with an additional 3 years in a leadership role (e.g. Manager or higher)
• Bachelor's Degree from an accredited college or university required, MBA or MHA strongly preferred
• Experience managing regulatory requirements and aligning operations to compliance with URAC requirements
• Excellent written and oral communication skills
• Strong analytical skills with attention to detail
• Ability to identify areas of improvement and develop action plans to address findings
• Positive, proactive team-oriented approach/attitude
• Strong knowledge of Microsoft Office products
• Holds a current, active, and unrestricted RN license that allows him/her to practice in a state or territory of the United States.

Equal Employment Opportunity Policy Statement

Lucent Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, color, creed, religion, alienage or national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity, gender expression, transgender status, sexual orientation, marital status, military service and veteran status.