Director of Utilization Mgmt - MediGold

Trinity Health • Columbus, OH

1d

About The Position

Why MediGold? MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. Position Purpose: Director Utilization Review directs the department's activities and resources to ensure alignment with the mission, values, and objectives of the department and organization What you will do: Develops and implements departmental strategic goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization. Oversees compliance with regulations, laws and ethics via audits and direct observation. Provides leadership in developing and implementing standardized tools, roles and systems to support Utilization Review Directs and evaluates departmental operations. Leads operational improvements to facilitate standardization of utilization review practices. Establishes metrics to achieve service targets. Oversees and evaluates programs and services focused on continuous quality improvement. Participates in review of contracts and agreement of services Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary and continuing education initiatives. Develops network of high performing teams Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates within the allocated funding Participates as an active management member of the Mount Carmel Health Plan representing the Utilization Review Department in collaboratively meeting operational, budget, and strategic planning goals

Requirements

• Education: Bachelor of Science Degree in Nursing, Business or other Healthcare related field.
• Licensure/ Certification: RN License through the State of Ohio
• Experience: 10+ years experience in clinical nursing and utilization management with at least 3+ years of utilization management experience at a Managed Care organization.
• Working knowledge of utilization review practices related to regulatory and accreditation requirements.
• Proven team leader with the ability to interact with all levels of staff members and physicians and other healthcare providers.
• Ability to prioritize issues and solve complex problems.
• Proficient computer, written and verbal communication skills including presentation skills.
• Innovative and self-directed.
• Demonstrates a high tolerance for ambiguity and change and provides leadership to department colleagues and others to adapt effectively to meet changing environment.

Nice To Haves

• Master's Degree preferred

Responsibilities

• Develops and implements departmental strategic goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization.
• Oversees compliance with regulations, laws and ethics via audits and direct observation.
• Provides leadership in developing and implementing standardized tools, roles and systems to support Utilization Review
• Directs and evaluates departmental operations.
• Leads operational improvements to facilitate standardization of utilization review practices.
• Establishes metrics to achieve service targets.
• Oversees and evaluates programs and services focused on continuous quality improvement.
• Participates in review of contracts and agreement of services
• Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary and continuing education initiatives.
• Develops network of high performing teams
• Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates within the allocated funding
• Participates as an active management member of the Mount Carmel Health Plan representing the Utilization Review Department in collaboratively meeting operational, budget, and strategic planning goals

Benefits

• Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

What This Job Offers

• Job Type: Full-time
• Career Level: Director