Director, Utilization Management – Physical Health

Alliance Health

. Administer and coordinate physical health utilization management activities for Alliance .

Posted 9/23/2026full-timeMorrisville • North Carolina • United StatesMid-LevelSenior💰 $119,264 - $152,062 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management principles and practices, with a strong focus on compliance, staff oversight, and data analysis to enhance patient care delivery. Proficient in developing policies and workflows while ensuring adherence to regulatory standards and effective communication with healthcare providers.

Highest-signal resume keywords

Utilization ManagementRegistered Nurse LicenseData AnalysisSupervisory ExperienceHealthcare Project Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization Management PrinciplesDiagnostic Treatment GuidelinesAuthorization StandardsAcute Clinical Utilization ReviewWorkflow Development

Soft Skills

Written CommunicationOral CommunicationProblem SolvingLeadershipCoaching

Tools & Technologies

Multiple Software ProgramsData Analysis Tools

Certifications & Qualifications

Registered Nurse License

Industry Keywords

Healthcare CompliancePatient Care DeliveryCo-Morbid Health ConditionsMedical Necessity CriteriaDelegation Agreements

About the role

Key responsibilities & impact

Administer and coordinate physical health utilization management activities for Alliance
Ensure the UM Department operates as an integrated department providing holistic member-needs reviews
Oversee staff, workflows, goals, performance, training, coaching, mentoring, and professional development
Maintain compliance with organizational policies, licensure, regulatory, accreditation, and contract requirements
Oversee delegated utilization management vendors and monitor compliance with delegation agreements and corrective action plans
Oversee reviews of physical health services and ensure consistent application of medical necessity criteria
Develop and implement department policies, procedures, authorization systems, and corrective plans
Protect client rights and ensure timely treatment-request processing and due process
Educate hospitals, nursing homes, and other care providers on departmental procedures and requirements
Analyze community service capacity, service gaps, utilization patterns, and evidence-based practices
Advise on Medicaid and Non-Medicaid benefit plans and Utilization Management Committee trends and performance measures
Collaborate with department heads, decision makers, Medical Directors, specialists, and primary care physicians
Perform other related duties as assigned by Alliance Health administration

Requirements

What you’ll need

Bachelor’s degree in Nursing with seven (7) years’ post-degree experience, including at least two (2) years of supervisory experience and two (2) years Utilization Management or substantially equivalent experience; OR Master’s degree in Nursing and five (5) years’ experience including at least two (2) years of supervisory experience and two (2) years Utilization Management experience or substantially equivalent experience
Registered Nurse license
Knowledge of Utilization Management managed care principles and strategies
Knowledge of physical health and co-morbid health conditions
Knowledge of diagnostic treatment guidelines/protocols and level of care criteria
Knowledge of authorization/re-authorization Utilization Management standards
Ability to analyze data and develop corresponding strategies
Ability to develop and document workflows
Written and oral communication skills
Ability to analyze process effectiveness and make adjustments
Experience in acute clinical utilization review
Experience in patient care delivery, patient care provider management, or healthcare project management
Ability to handle complex and confidential sensitive situations
Ability to lead, delegate, and problem solve
Proficiency in computers and multiple software programs
Ability to assist appeal efforts when medical care is denied by payor entities

Benefits

Comp & perks

Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
Dress flexibility