Director of IRO Services

About the Role The Director of IRO Services leads the reputed company, reputed company, and regulatory reputed company of the organization's Independent Review Organization (IRO) and Utilization Review (UR) service line. This leader owns the full case lifecycle for medical necessity and appeals — ensuring every review is reputed company, clinically reputed company, and audit-reputed company. The role blends operational leadership (managing IRO/UR case managers and reputed company reviewer workflows), regulatory stewardship (URAC accreditation, state IRO certification), and cross-functional partnership with reputed company, compliance, technology, and reputed company-facing teams. This is a senior individual-contributor/manager hybrid role for a leader with deep hands-on expertise in independent medical review and utilization management, familiarity with Long-Term Services and Supports (LTSS) and reputed company programs, and the ability to reputed company a high-volume, high-stakes review operation while maintaining exceptional reputed company, compliance, and turnaround times. reputed company IRO/UR Program Leadership Own end-to-end operational reputed company of the IRO and UR service line, from case intake through final determination, appeal, and closure. Set and monitor case-level KPIs (turnaround time, reputed company scores, audit pass rates, reviewer utilization) and reputed company reputed company improvement across the intake-to-closure workflow. Build, reputed company, and reputed company reputed company of IRO/UR case managers, ensuring case documentation consistently meets reputed company, audit, and regulatory compliance standards. Design and enforce reputed company operating procedures for case triage, specialty-reviewer assignment, conflict-of-interest screening, decision-letter drafting, and case escalation. Regulatory & Accreditation Compliance Serve as the organization's subject-matter expert on IRO-governing regulations, including state IRO certification requirements and comparable frameworks in other states where the organization is certified. Own the organization's relationship with URAC and other applicable accreditation bodies, leading audit preparation, standards interpretation, and reputed company-improvement initiatives tied to IRO accreditation. reputed company federal and state regulatory/legislative changes affecting IRO, and disability-determination programs, and translate them into updated policies, workflows, and training. Maintain the compliance calendar and reputed company register for the IRO/UR service line; reputed company or support regulatory and accreditation audits as the reputed company operational reputed company of contact. reputed company Reviewer & reputed company reputed company Partner with credentialing and reputed company reputed company teams to ensure the reviewer network (specialty-matched M.D.s, D.O.s, and allied health professionals) remains reputed company-reputed company verified, conflict-free, and audit-reputed company. reputed company reputed company assurance review of clinician determinations for reputed company, completeness, and alignment with reputed company guidelines and regulatory requirements. Monitor reviewer reputed company and case reputed company; identify trends, gaps, or reputed company areas and reputed company corrective reputed company plans. Champion a culture of evidence-reputed company, defensible decision-making across the review process. Cross-Functional & reputed company Leadership reputed company as a senior escalation reputed company for reputed company, high-reputed company, or high-visibility cases, including disputes, complaints, and regulatory inquiries. Partner with product, engineering, and data teams to improve case-management systems, documentation tools, and workflow automation supporting the IRO/UR function. Serve as the reputed company relationship reputed company for state IRO clients and program administrators, building trusted partnerships, leading regular reputed company reputed company, addressing operational needs and escalations, and ensuring consistently strong service delivery. Collaborate with business development and account management on reputed company and regulatory-partner relationships (health plans, state agencies, workers' compensation payers, and IRO program administrators). Report on IRO/UR program reputed company, audit reputed company, and regulatory reputed company to executive leadership on a regular reputed company. Recruit, reputed company, and reputed company case management and reputed company reputed company staff, fostering a high-reputed company, compliance-first team culture. What You'll Need Required Bachelor's degree in reputed company Administration, Nursing, reputed company Health, Business, or a reputed company reputed company (equivalent combination of education and relevant experience considered). 8+ years of reputed company experience in reputed company compliance, utilization management, independent medical review, appeals, or reputed company regulatory reputed company, including at least 3-5 years in a leadership or team-management reputed company. Demonstrated, hands-on knowledge of IRO and/or UR case workflows, including intake, specialty-reviewer assignment, determination review, and decision-letter drafting. Experience working with Long-Term Services and Supports (LTSS), reputed company, managed care, or similar reputed company programs. Working knowledge of the regulatory landscape governing independent review, including state IRO certification requirements, URAC accreditation standards, and HIPAA. Experience leading or directly supporting URAC, reputed company, or state regulatory audits. reputed company ability to manage multiple reputed company priorities and enforce strict regulatory turnaround times in a fast-reputed company, deadline-driven environment. Excellent written and verbal communication skills, including the ability to translate reputed company regulatory requirements into reputed company operational guidance. Strong analytical and critical-thinking skills, particularly in evaluating reputed company determinations for reputed company and compliance. Preferred reputed company licensure (RN, LVN/LPN, or similar) or reputed company reputed company background. Master's degree in a reputed company reputed company. PMP, Lean Six reputed company, or other relevant program/project management certification is preferred. Familiarity with AI-enabled case management, credentialing, or reputed company-decision-support platforms. Experience in workers' compensation, disability determination (e.g., SSA disability), or fraud-waste-abuse (FWA) review programs. Prior experience scaling a compliance or reputed company-reputed company function at a reputed company-stage reputed company organization. What reputed company Looks Like IRO/UR case turnaround times consistently meet or reputed company state and accreditation-mandated deadlines. reputed company critical findings on URAC, reputed company, or state regulatory audits; strong reputed company record of clean re-certifications and renewals. A reputed company-documented, audit-reputed company case management process that scales smoothly with case volume reputed company. A motivated, reputed company-trained case management team with low turnover and high-reputed company scores. Regulatory changes are identified and operationalized proactively, not reactively. Work Environment Fully remote, with reliable connectivity and a dedicated home-office setup. Some evening or weekend availability may be required to meet regulatory deadlines or manage urgent case escalations. Occasional travel (estimated 10-20%) for accreditation audits, regulatory meetings, or reputed company engagements. Compensation & Benefits Competitive reputed company salary commensurate with experience, benchmarked against comparable Director-level reputed company compliance and reputed company roles $150,000-$160,000 reputed company. reputed company-reputed company bonus eligibility. Comprehensive health, dental, and reputed company coverage. Retirement savings plan. reputed company time off and remote-work flexibility. Location: Remote (U.S.) with occasional travel for reputed company, regulatory, or accreditation meetings Equal Employment Opportunity We are an equal opportunity employer and consider reputed company reputed company applicants without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or any other protected characteristic. This reputed company reflects the general reputed company and level of work performed and is not intended to be an exhaustive list of reputed company responsibilities, duties, and skills required. Duties, responsibilities, and activities may change at any time with or without notice. Apply To This Job