Manager, Medical Utilization and Care Management
About The Position
Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels. At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health .
Requirements
- Active unrestricted RN license (BSN preferred)
- 5+ years of experience in utilization management, care management, or case management
- 2+ years leadership experience
- Knowledge of medical necessity reviews, care coordination models, and payer systems
Nice To Haves
- Certification (CCM, CMGT-BC, HCQM).
- Experience with Commercial, Medicare and Medicaid population.
- Experience working with Medical Directors, Vendors, and Health Systems.
- Knowledge of URAC/NCQA standards.
Responsibilities
- Provide oversight for vendors conducting utilization management, care management, and clinical operations activities.
- Oversee vendor execution of utilization reviews, including prospective, concurrent, and retrospective reviews, to ensure medical necessity and appropriate level of care determinations.
- Monitor vendor review of medical records and treatment plans to support appropriate service utilization, avoid unnecessary or duplicate services, and optimize reimbursement outcomes.
- Partner with the Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations.
- Provide oversight of vendor-managed prior authorization, peer-to-peer review, denial, appeal, and notification processes.
- Ensure vendors complete comprehensive biopsychosocial assessments and health risk assessments (HRAs) in accordance with program requirements.
- Oversee vendor-led care coordination across the continuum, including transitions of care and discharge planning.
- Provide oversight of vendor-administered chronic disease and complex case management programs.
- Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care.
- Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented.
- Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements.
- Coordinate with vendor interdisciplinary teams, including nurses, social workers, and care coordinators, to promote aligned clinical operations and member outcomes.
- Promote vendor-delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
