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Senior Director, Regional Utilization Management
Primary Location Portland, Oregon
Schedule Full-time
Shift Day
Salary $178600 - $231110 / year
Job Number 1373325
Date posted 07/29/2025
Job Summary:
Under the direction of a Health Plan Senior Leadership Team member, the Regional Sr. Director serves as the senior Utilization Management leader providing strategic direction to design, develop, and oversee the execution of the Regional Utilization Management (UM) Program and the application of medical necessity criteria and contracted member coverage. The Senior Director of UM has overall accountability for the comprehensive UM program even when daily operations are performed by other teams. UM is performed in a highly regulatory environment, and the Sr. Dir ensures performance that meets strict compliance and regulatory requirements.
The Regional Sr. Director manages the overall, regionwide operations and teams for ambulatory utilization management, prior authorization, and referral authorization functions ensuring the accurate and timely authorization of designated health care services. This includes representing the KPNW Utilization Management Program as KP national forums, committees, and governances, as well as representing the KPNW UM Program externally with customers, regulators, providers, community organizations, and members.
The Sr. Director partners and coordinates within KPNW, and across other KP regions, to educate, adopt standard tools, and drive complex, strategic UM and Resource Stewardship initiatives for high quality, cost-effective healthcare outcomes. The Sr. Director partners directly with the NW Permanente Group leadership and NWP Medical Director, Vice President of Continuing Care, Pharmacy Leadership, Quality, Network Management, and the NHP UM team to drive regional strategic priorities.
Essential Responsibilities:
- Responsible for the strategic planning and decision-making related to utilization reviews and the overall utilization management program. In partnership with the National Health Plan UM team, develops and implements departmental policies and procedures. Develops, implements and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients
- Directly manages the administrative and operational functions of the Regional ambulatory utilization management department.
- Develops standards and minimum requirements for utilization management administration performed in areas outside of the Regional UM team, including but not limited to Continuing Care and Pharmacy to comply with regulatory requirements and professional best practice.
- Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefits and clinical guidelines or criteria. Ensures consistent application of medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, costs, operations and forecast data to determine progress toward utilization management goals and objectives. Complies and reviews multiple reports for statistical and financial tracking to identify utilization trends and make recommendations to management and ensure inter-rater reliability of staff performance.
- Co-Chairs with a NWP medical leader the regional UM Committee to monitor compliance with health plan national and state regulatory/accreditation requirements and medical standards of practice related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met. Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits.
- Represents region at national UM-related committees and workgroups and reports regional adherence to national standards and performance metrics. Engages in cross-market improvement initiatives.
- Ensures compliance with all UM related laws, regulations, and contractual requirements. Forecasts and establishes survey readiness activities to maintain compliance with regulatory standards and defines standards for audit documentation.
- Manages and oversees the utilization review management training and education program for Utilization Review leaders and staff across the region. Ensures post-course evaluation tools and other materials are developed. Manages training and education schedules.
- Manages clinical and non-clinical UM staff including hiring, training, performance evaluations and terminations. Ensures tools and technology are created and improved to perform activities and ensure timely and appropriate documentation for accurate data capture and reporting.
- Facilitates on-going communication and manages relationships among utilization management staff, internal providers care management peers and leaders, and external/contracted providers. Manages performance and issues with internal and external representatives regarding Union issues as necessary
- Develops department business plan and develop multi-year strategic roadmap to increase functional capabilities to meet business objectives and market needs. Ensures short and longrange financial goals are met by establishing and controlling the department budget.
- Recruits hires, trains, develops, coaches and mentors of staff with a goal of developing and retaining talent within the organization. Provides guidance and leadership to highly matrixed cross-functional teams.
- Develops and builds high-performing teams with a focus on delivering business value, incorporating industry standard and innovative approaches and tools to achieve value outcomes.
- Develops plans and executes department based budgeting and identify priorities to best manage both internal and external costs. Monitors department finances.
- Establishes departmental goals and objectives that are consistent with, and lead to the successful achievement of, regional goals and objectives. Consults with executive management for effective integration of performance metrics to monitor the success of strategic improvement projects across the organization.
- Continually assess the effectiveness of departmental functioning, including the people, processes and technologies needed to achieve departmental and regional goals and objectives. Identify problems and opportunities.
Basic Qualifications:
Experience
- Minimum nine (9) years of progressive experience in business operations, clinical health care, or a directly related field.
- Minimum four (4) years of experience in a leadership role with direct reports.
- Minimum seven (7) years of customer or member/patient service experience.
- Minimum four (4) years of experience managing operational or project budgets.
Education
- Bachelors degree in a business, nursing, health care, or directly related field OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A
Additional Requirements:
- Thorough knowledge of utilization management and clinical practice
- Familiarity with Medicare and Medicaid Managed care practices and policies, CHIP and SCHIP
- Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP))
- Change Management; Business Process Improvement; Compliance Management; Confidentiality; Health Care Compliance; Maintain Files and Records; Financial Acumen; Employee Training; Employee/Labor Relations; Onboarding; Position Requirements;
- Workforce Planning; Conflict Resolution; Stakeholder Management; Vendor Management; Legal And Regulatory Requirements; Calendar Management; Member Service; Microsoft Office; Health Care Quality Standards; Information Systems; Union Work Environment; Training; Outcome Driven Innovation.
Preferred Qualifications:
- Seven (7) years of project/program management and/or implementationrelated experience.
- Seven (7) years of experience in process improvement.
- Masters degree in Business, Nursing, Health Care, or related field
- Clinical license including registered nurse, licensed independent clinical social worker, or other healthcare related licensure.
Primary Location: Oregon,Portland,Kaiser Permanente Building
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Flexible
Employee Status: Regular
Employee Group/Union Affiliation: NUE-NW-01|NUE|Non Union Employee
Job Level: Director/Senior Director
Department: Kaiser Permanente Building - Utilization Management - 1008
Pay Range: $178600 - $231110 / year
Travel: No
Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.
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