Manager | Utilization Management Services
About The Position
At Emplify Health, we are committed to creating healthier communities through exceptional patient care, innovation, and teamwork. This is a unique opportunity to lead our Utilization Management Services team during a time of exciting transformation and alignment across the organization. As Manager of Utilization Management Services, you'll play a key role in advancing best practices, optimizing workflows, and supporting the implementation of innovative technologies that enhance efficiency and outcomes. In this role, you'll provide leadership to a team of approximately 20 professionals while partnering closely with physicians, medical directors, and operational leaders. You'll help ensure appropriate level-of-care determinations, regulatory compliance, and reimbursement optimization while guiding your team through ongoing change and growth initiatives.
Requirements
- Associate degree in Nursing or Health Information Management with RHIT certification.
- Active Registered Nurse (RN) license in the state of practice, or RHIT/RHIA credential as applicable.
- Minimum of five years of Utilization Management experience.
- Supervisory or leadership experience within a healthcare environment.
Nice To Haves
- Bachelor's degree in Nursing or Health Information Management with RHIA certification.
- Three or more years of supervisory or leadership experience.
- Case Management certification (ACM or CMSA).
- Experience leading process improvement, workflow optimization, or change management initiatives.
- Deep expertise in Utilization Management and medical necessity review.
- Proven success leading teams through change and transformation initiatives.
- Strong communication and relationship-building skills with physicians, clinicians, and operational leaders.
- The ability to balance regulatory, financial, and patient-centered priorities.
- A forward-thinking mindset and enthusiasm for innovation, technology, and AI-enabled solutions.
- Strong critical thinking, decision-making, and problem-solving abilities.
- A collaborative leadership style focused on engagement, accountability, and continuous improvement.
Responsibilities
- Provide operational and administrative leadership for Utilization Management Services.
- Lead and develop a department of approximately 20 team members, including Utilization Management Specialists and support staff.
- Oversee utilization review operations, medical necessity determinations, denials management, and appeals processes.
- Partner with physicians, medical directors, clinicians, and organizational leaders to drive effective utilization management practices.
- Ensure compliance with regulatory, payer, and organizational requirements.
- Monitor department performance and align fiscal responsibility with reimbursement optimization goals.
- Lead workflow improvement initiatives and support the adoption of new technologies, including AI-enabled tools.
- Foster a culture of accountability, collaboration, continuous improvement, and adaptability.
Benefits
- Comprehensive benefits package and competitive retirement program.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
