Director of IRO Services

About the Role

The Director of IRO Services leads the strategy, operations, and regulatory integrity 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 timely, clinically sound, and audit-ready. The role blends operational leadership (managing IRO/UR case managers and clinical reviewer workflows), regulatory stewardship (URAC accreditation, state IRO certification), and cross-functional partnership with clinical, compliance, technology, and client-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 Medicaid programs, and the ability to scale a high-volume, high-stakes review operation while maintaining exceptional quality, compliance, and turnaround times.

What You'll Do

IRO/UR Program Leadership

• Own end-to-end operational performance of the IRO and UR service line, from case intake through final determination, appeal, and closure.
• Set and monitor case-level KPIs (turnaround time, quality scores, audit pass rates, reviewer utilization) and drive continuous improvement across the intake-to-closure workflow.
• Build, lead, and develop a team of IRO/UR case managers, ensuring case documentation consistently meets quality, audit, and regulatory compliance standards.
• Design and enforce standard 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 continuous-improvement initiatives tied to IRO accreditation.
• Track 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 risk register for the IRO/UR service line; lead or support regulatory and accreditation audits as the primary operational point of contact.

Clinical Reviewer & Quality Oversight

• Partner with credentialing and clinical operations teams to ensure the reviewer network (specialty-matched M.D.s, D.O.s, and allied health professionals) remains primary-source verified, conflict-free, and audit-ready.
• Oversee quality assurance review of clinician determinations for accuracy, completeness, and alignment with clinical guidelines and regulatory requirements.
• Monitor reviewer performance and case outcomes; identify trends, gaps, or risk areas and drive corrective action plans.

Champion a culture of evidence-based, defensible decision-making across the review process.

Cross-Functional & Client Leadership

• Act as a senior escalation point for complex, high-risk, 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 primary relationship owner for state IRO clients and program administrators, building trusted partnerships, leading regular client touchpoints, addressing operational needs and escalations, and ensuring consistently strong service delivery.
• Collaborate with business development and account management on client and regulatory-partner relationships (health plans, state agencies, workers' compensation payers, and IRO program administrators).
• Report on IRO/UR program performance, audit outcomes, and regulatory risk to executive leadership on a regular cadence.
• Recruit, coach, and develop case management and clinical operations staff, fostering a high-performance, compliance-first team culture.

What You'll Need

Required

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Business, or a related field (equivalent combination of education and relevant experience considered).
• 8+ years of progressive experience in healthcare compliance, utilization management, independent medical review, appeals, or related regulatory operations, including at least 3-5 years in a leadership or team-management capacity.
• 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), Medicaid, managed care, or similar healthcare 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, NCQA, or state regulatory audits.
• Proven ability to manage multiple concurrent priorities and enforce strict regulatory turnaround times in a fast-paced, deadline-driven environment.
• Excellent written and verbal communication skills, including the ability to translate complex regulatory requirements into clear operational guidance.
• Strong analytical and critical-thinking skills, particularly in evaluating clinical determinations for accuracy and compliance.

Preferred

• Clinical licensure (RN, LVN/LPN, or similar) or direct clinical background.
• Master's degree in a related field.
• PMP, Lean Six Sigma, or other relevant program/project management certification is preferred.
• Familiarity with AI-enabled case management, credentialing, or clinical-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 clinical-operations function at a growth-stage healthcare organization.

What Success Looks Like

• IRO/UR case turnaround times consistently meet or beat state and accreditation-mandated deadlines.
• Zero critical findings on URAC, NCQA, or state regulatory audits; strong track record of clean re-certifications and renewals.
• A well-documented, audit-ready case management process that scales smoothly with case volume growth.
• A motivated, well-trained case management team with low turnover and high-quality 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 client engagements.

Compensation & Benefits

• Competitive base salary commensurate with experience, benchmarked against comparable
• Director-level healthcare compliance and operations roles $150,000-$160,000 base.
• Performance-based bonus eligibility.
• Comprehensive health, dental, and vision coverage.
• Retirement savings plan.
• Paid time off and remote-work flexibility.

Location: Remote (U.S.) with occasional travel for client, regulatory, or accreditation meetings

Equal Employment Opportunity

We are an equal opportunity employer and consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.

This job description reflects the general nature and level of work performed and is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Duties, responsibilities, and activities may change at any time with or without notice.