Manager of Utilization Management
About The Position
The Manager of Utilization Management (UM) is responsible for overseeing and directing the organization’s utilization management program to ensure appropriate use of healthcare services, regulatory compliance, and high-quality patient care outcomes. Under the direction of senior leadership, the UM Manager supervises daily UM operations, including prospective, concurrent, and retrospective review activities, while ensuring adherence to CMS, DMHC, and health plan requirements. This role provides leadership to UM staff, supports clinical decision-making processes, ensures timely authorization determinations, and promotes efficient healthcare resource utilization through effective team management, process improvement, and cross-functional collaboration.
Requirements
- Associate’s degree or completion of Vocational Nursing Program.
- At least five years of experience in utilization management, case management, or managed care and at least one year of leadership or supervisory experience.
- Current California Licensed Vocational Nurse (LVN) license in good standing and Basic Life Support (BLS) certification preferred
- Strong knowledge of utilization management principles and medical necessity criteria
- In-depth understanding of CMS, DMHC, and health plan regulations
- Leadership, coaching, and team development skills
- Strong analytical, problem-solving, and decision-making abilities
- Ability to manage multiple priorities in a fast-paced environment
- Excellent written and verbal communication skills
- Proficiency with EMR systems and UM platforms
- Strong organizational and time management skills
Nice To Haves
- Bachelor’s Degree in Nursing, Healthcare Administration, or related field.
- Clinical nursing experience.
- Experience in a health plan, MSO, IPA, or managed care environment.
- Experience with Medicare Advantage and Medi-Cal populations.
- Experience with InterQual, MCG, or similar criteria.
- Familiarity with EZ-Cap, EZ-Net, DocStar, or similar systems.
- Knowledge of ICD-10, CPT, and HCPCS coding.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
