The Director of Utilization facilitates the clinical design and implementation of Central Health’s Utilization program.
This leadership position will be responsible for ensuring that appropriate and cost-effective medical care is
delivered directly or through contracted services, while developing and implementing programs to improve quality,
cost, and clinical outcomes. The Director of Utilization will serve as a strategic advisor to enhance clinical
operations, cost-effective utilization of resources and health care delivery for Central Health.
This position may also serve as a member of the Medical Executive Board and its committees and will be
responsible for developing and delivering effective public presentations to the Central Health Board of Managers, its
committees, board meetings, stakeholders and partners, and the public.

JOB FUNCTIONS
Essential Functions
Work in tandem with Central Health Leaders to establish and deliver on quality, growth, community partnerships
and fiscal objectives
Work with the Chief and Associate Chief Medical Officers, Provider Relations and Operational teams and other
stakeholders to ensure that clinically appropriate and cost-effective medical care is delivered to Central Health
patients
Develop programs to improve quality, cost, and outcomes
Owns the process to integrate Utilization with Central Health medical services including authorization for services,
level of care pre-certification, concurrent review, medical claims reconsideration and retrospective review
determinations, retrospective clinical denial management and reporting, approval for procedures and other areas
Lead the implementation of utilization care management initiatives to improve quality and financial outcomes, with
a focus on high utilizers
Interpret medical policies and guidelines to establish delivery of timely, appropriate and cost-effective care.
Develop and maintain relationships with internal and community partners
Promote Central Health’s adherence to government (CMS) policies regarding level of care and medical necessity
determinations
Lead the recruitment, onboarding, development and ongoing management of the Utilizations team as needed
Identify and address program needs and make recommendations for process and quality improvement
opportunities
Promote, recommend and coordinate high evidence-based standards
Demonstrate expertise in relevant medical practices, protocol, trends and best practices in clinical areas assigned
Demonstrate knowledge and success in affecting overall clinical operations.
Coordinate with the ACMO and VP, Operations to understand the scope of contracted and direct practice services,
helping to inform decisions and recommendations regarding the development, deployment, and oversight of safe,
effective, and efficient clinical services for Central Health’s covered population
Other duties as assigned

Required:

Unrestricted license to practice medicine in the State of Texas. 
Board Certified in area of specialty. 
Current Drug Enforcement Agency (DEA) registration for the purpose of writing prescriptions.
Credentialed by the Medical Executive Board. 
Current Healthcare Provider Cardiopulmonary Resuscitation (CPR) from the American Heart Association or the American Red Cross.