Job Description
Utilization Management Director Healthcare is increasingly unaffordable for many Americans. For those who can afford it, they are in a health insurance system that has become more confusing, restrictive, and lower value with each passing year. Here at WeShare our mission is to bring better healthcare to America at a better price. We offer consumers a member-to-member health sharing program that is much more cost effective than standard health insurance while providing access to over 1.2 million physicians across the country. Come join us on this important journey to create the next generation of healthcare! WeShare is a rapidly growing faith-based nonprofit that strives to do good while delivering great and affordable healthcare. The company is led by senior executives with an extensive background in both for-profit and not-for-profit enterprises. If you have a bias for action, enjoy challenges, and love creating impact in a massive industry, WeShare might be the place for you! About this role The Utilization Management Director will be responsible for building and leading UHSM’s first internal clinical utilization management function. This role will establish the structure, processes, policies, and team supporting end-to-end utilization management and clinical review functions, including medical necessity determinations, prior authorization, concurrent and retrospective review, Shared Medical Bills (SMB) clinical review, appeals support, and associated provider and member communications. This is a foundational leadership role for the organization. The Director will partner closely with SMB, Provider Services, Member Services, Compliance, Operations, and executive leadership to establish a clinically sound, compliant, member-centered, and operationally efficient utilization management program. The ideal candidate is a licensed clinical professional with strong utilization management experience, payer or managed care knowledge, and the ability to build a department from the ground up. Key Responsibilities Department Buildout & Clinical Leadership Develop and launch UHSM’s internal Utilization Management and Clinical Operations function, including workflows, policies, procedures, staffing models, documentation standards, and performance metrics. Inform design and implementation of a Salesforce-based clinical case management platform, partnering with internal and technical teams to define requirements, configure workflows, and optimize utilization management operations. Drive evaluation and selection of a clinical guideline engine (medical necessity criteria tool) and oversee integration with the case management system to support prior authorization, concurrent, and retrospective review workflows. Establish clinical review processes for prior authorization, pre-service review, concurrent review, retrospective review, medical necessity review, and SMB-related clinical evaluation and underwriting. Build and lead a clinical team, which may include UM nurses, clinical reviewers, care coordinators, clinical operations specialists, and administrative support staff. Create clear role definitions, training plans, quality review processes, and performance expectations for clinical team members. Serve as the organization’s subject matter expert on utilization management, clinical review operations, and medical necessity processes. Utilization Management Program Oversight Oversee the review of requested healthcare services to support appropriate, evidence-based, timely, and consistent determinations. Ensure clinical reviews are based on relevant clinical documentation, plan/program guidelines, recognized clinical criteria, and applicable regulatory or accreditation standards. Develop processes for urgent and non-urgent reviews, provider communication, additional information requests, peer review escalation, and documentation of determinations. Monitor utilization trends, high-cost services, inpatient stays, readmissions, out-of-network utilization, gaps in care coordination, and other clinical cost drivers. Partner with leadership to identify opportunities to improve clinical outcomes, reduce avoidable costs, and strengthen member/provider experience. Clinical Governance, Compliance & Quality Develop policies and procedures aligned with appropriate utilization management standards, including medical necessity review, clinical criteria use, denial documentation, appeals support, and peer review escalation. Partner with Compliance to ensure utilization management processes meet applicable federal, state, contractual, and organizational requirements. Support audit readiness and maintain accura