Director, Utilization Management

SUMMARY:

The Director of Utilization Management (UM) is a critical dual-function leadership role at PACE Southeast Michigan, sitting at the intersection of our clinical delivery model and our insurance Plan obligations. Reporting directly to the Medical Director, this role owns the full utilization management program — including prospective, concurrent, and retrospective review — and serves as the primary check and balance between the IDT's care decisions and the financial stewardship required of a capitated, dual payer-provider PACE organization.

This position works in close partnership with the Chief Financial Offer to ensure that utilization patterns, service authorization decisions, and medical necessity determinations are grounded in both clinical evidence and financial accountability. The Director of UM is not a denial-focused role — it is a data-driven, relationship-oriented leadership position that helps PACE SEMI deliver the right care, in the right setting, at the right time, for every participant we serve.

KEY RESPONSIBILITIES:

Utilization Management Program Leadership:

• Own and operate the full UM program — prospective, concurrent, and retrospective review — ensuring every authorization decision is clinically justified and financially responsible.
• Develop, implement, and continuously improve UM policies, procedures, and workflows aligned with PACE model of care requirements.
• Apply evidence-based clinical criteria (InterQual, MCG) to medical necessity determinations across all care settings — home, adult day, inpatient, SNF, specialist, and ancillary.
• Review complex and high-cost cases, escalating to the Medical Director for final medical necessity determination when required.
• Maintain audit readiness and ensure documentation standards meet CMS, state Medicaid, and PACE regulatory requirements.

Concurrent Review & Inpatient Census Management:

• Maintain a real-time census of all participants in inpatient hospital or SNF settings across all ten centers.
• Conduct or oversee daily concurrent review of all inpatient stays — actively managing length of stay, monitoring clinical justification for continued care, and coordinating discharge planning with the facility and IDT.
• Run a regular census review call with center directors and clinical leadership to ensure organizational visibility on high-acuity participants.
• Partner with contracted hospitals and SNFs to drive appropriate, timely discharge and prevent avoidable days.

IDT Collaboration & Financial Stewardship:

• Attend IDT meetings on a regular basis to provide UM perspective on care plan decisions and high-cost service authorizations.
• Serve as the financial stewardship voice in clinical conversations — not to override the IDT but to ensure care decisions are made with full awareness of cost, capitation impact, and alternative care settings.
• Partner with the Chief Financial Offer to track utilization trends against the capitation model and identify cost drivers requiring intervention.
• Provide regular UM performance reporting to the Medical Director and Chief Financial Offer including inpatient days per thousand, SNF utilization, readmission rates, and authorization denial/appeal trends.

Prior Authorization Oversight:

• Provide leadership and clinical oversight to the Manager of Prior Authorization and the prior authorization workflow.
• Establish authorization criteria, turnaround time standards, and escalation protocols for complex or high-cost requests.
• Ensure prior authorization decisions are consistent, compliant, and well-documented for audit purposes.

Network & Provider Collaboration:

• Build and maintain working relationships with key hospitals, SNF partners, and specialty providers to support appropriate utilization and efficient care transitions.
• Collaborate with the Director of Network & Contracting on utilization data that informs contract negotiations and network performance evaluation.
• Evaluate provider patterns related to length of stay, readmissions, and over-utilization and escalate concerns through appropriate channels.

Compliance, Quality & Regulatory:

• Ensure UM program compliance with all CMS, state Medicaid, and PACE-specific regulatory requirements including Notice of Medicare Non-Coverage (NOMNC) and coverage determination timelines.
• Collaborate with the Corporate Compliance Officer on grievances and appeals that involve UM decisions.
• Support QAPI initiatives related to utilization, readmissions, and avoidable hospitalizations.
• Maintain records and reporting required for annual CMS program audit and state oversight activities.

Team Leadership & Development:

• Directly supervise the Manager of Prior Authorization and Manager of Concurrent Review & Census.
• Provide coaching, mentorship, and professional development support to the UM team.
• Foster a culture of clinical accountability, continuous improvement, and collaborative problem-solving.

QUALIFICATIONS & REQUIREMENTS:

Candidates must hold an active, unrestricted professional clinical license in the State of Michigan. Qualifying licenses include:

• Registered Nurse (RN)
• Licensed Master Social Worker (LMSW)
• Licensed Clinical Social Worker (LCSW)
• Other relevant clinical or healthcare professional licensure may be considered based on experience and scope of practice

Regardless of licensure type, the successful candidate must demonstrate deep knowledge of clinical care settings, medical necessity criteria, and utilization management practice applicable to frail elderly populations

EDUCATION:

• Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field — or equivalent professional experience — preferred, but not required for candidates with strong equivalent professional experience.
• Master's degree in Nursing (MSN), Social Work (MSW), Healthcare Administration (MHA), or Public Health (MPH) — preferred, but not required for candidates with strong equivalent professional experience.
• Equivalent professional experience is defined as 10+ years of progressively responsible clinical and utilization management experience demonstrating the knowledge and competency consistent with a degree-level education in a related field.

EXPERIENCE:

• 7–10 years of clinical and/or utilization management experience. (required)
• 3–5 years of progressive leadership or supervisory experience in a UM, managed care, or health plan environment. (required)
• Direct experience in PACE, managed care, Medicare Advantage, or Medicaid managed care. (strongly preferred)
• Experience working with geriatric or frail elderly populations. (preferred)
• Demonstrated experience with InterQual and/or Milliman Care Guidelines (MCG) criteria. (required)
• Experience managing inpatient census and concurrent review programs. (required)

KNOWLEDGE, SKILLS & ABILITIES:

• Deep knowledge of CMS PACE regulations, Medicare, and Medicaid managed care requirements.
• Strong analytical skills — ability to interpret utilization data, identify trends, and translate findings into actionable interventions.
• Ability to work effectively within an Interdisciplinary Team model and navigate clinical-financial tension constructively.
• Excellent communication and relationship-building skills with clinical staff, executive leadership, and external providers.
• Proficiency with electronic health records (EHR)

CERTIFICATIONS (Preferred):

• Certified Case Manager (CCM)
• Accredited Case Manager (ACM)
• Certification in Utilization Management or Managed Care