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The Associate Director, Health Services Nursing is responsible for driving excellence in utilization management (UM) clinical operations through process improvement initiatives, process development, market enablement, targeted process audits, and training facilitation. This role oversees new market implementations, leads inter-rater reliability (IRR) processes, and ensures adherence to relevant policies and regulations. The Associate Director, Health Services Nursing collaborates across clinical and operational teams to advance best practices, support strategic growth, optimize performance and advance best practices in UM.

The Associate Director, Health Services Nursing is responsible for leading the development, optimization, and continuous improvement of UM processes and workflows.

• Oversee new market implementations, ensures compliance with organizational and regulatory policies, and collaborate with clinical and operational teams to drive strategic initiatives.
• Evaluate market readiness and operational requirements, develop strategies to address identified gaps, and support efforts that ensure new and existing markets are fully functional and compliant within utilization management.
• Provide expertise and leadership necessary to assess market needs, develop entry strategies, and coordinate cross-functional efforts.
• Ensure compliance with regulatory requirements, industry best practices, and organizational standards.
• Own and support inter-rater reliability (IRR) processes, promoting consistency in clinical decision-making and ongoing reviewer alignment.
• Conduct targeted process audits to identify improvement opportunities, mitigate risks, and ensure compliance with regulatory requirements, industry best practices, and organizational standards.
• Design and refine UM policies and procedures, direct process improvement projects, support policy development and implementation, and prepare performance reports for senior leadership.
• Facilitate training sessions, workshops, and collaborative meetings to engage stakeholders, promote best practices, and ensure staff proficiency in UM protocols.
• Monitor regulatory changes and industry trends to proactively inform process and policy updates, providing guidance and training to UM staff.
• Drives continuous process improvement initiatives that enhance efficiency, quality, and member experience within UM.

Use your skills to make an impact
 

Required Qualifications

• An active, unrestricted, Registered Nurse (RN) license.
• Five (5) or more years of professional experience working in the health care industry and/or in utilization management/utilization review.
• Two (2) or more years of formal leadership experience.
• Progressive leadership experience hiring, training, and managing associates.
• Highly adept at managing processes from concept to completion ensuring on-time, on-budget, and on-target results.
• Proficiency in analyzing and interpreting data trends.
• Experience in reviewing and analyzing financial, quality, and utilization data and analytics.
• Project management experience. 
• Comprehensive knowledge of all Microsoft Office applications, specifically Excel, and PowerPoint.
• Ability to use a variety of electronic information applications/software programs including electronic medical records.
• Ability to identify, structure and solve business problems.
• Excellent interpersonal, organizational, written, and oral communication and presentation skills.

Preferred Qualifications

• BSN, bachelor’s in business, health services or a related field.
• Medicare and Managed care experience working for similar health plans.

Additional Information

• Workstyle: This is a remote position.
• Travel: This role may require up to 10% travel for onsite meetings, which could include locations outside your state of residence.
• Typical Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).
• Direct Reports: Up to 10 associates.

WAH Internet Statement

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinoi