Referral and Patient Care Manager

PCC MEDICAL HOLDINGS LLC•West Palm Beach, FL

3d•$55,000 - $70,000•Hybrid

About The Position

The Manager, Referral and Case Management/Utilization Review is responsible for leading the day-to-day operations of the referral processing and case management/utilization review team. This role ensures timely, clinically appropriate, and compliant decisions on referrals, prior authorizations, and ongoing case management activities. The Manager oversees staff performance, applies evidence-based clinical criteria (including Milliman Care Guidelines/MCG), and works cross-functionally to support appropriate utilization of healthcare resources, regulatory compliance, and quality outcomes.

Requirements

Active, unrestricted clinical license required: RN (Registered Nurse) strongly preferred; other clinical licensure (e.g., LPN with case management experience, LCSW) may be considered depending on organizational scope.
Minimum 3–5 years of experience in utilization review, case management, or referral management within a managed care, health plan, or clinical setting.
Minimum 1–2 years of supervisory or team lead experience.
Demonstrated working knowledge and hands-on experience applying Milliman Care Guidelines (MCG) or equivalent nationally recognized utilization criteria (e.g., InterQual).
Strong understanding of medical necessity review, prior authorization, concurrent review, and discharge planning processes.
Familiarity with regulatory/accreditation standards (CMS, NCQA, URAC, state Medicaid/Medicare requirements) as applicable.
Strong clinical judgment and decision-making under regulatory/timeliness pressure.
Leadership and team management skills, including performance management and coaching.
Excellent written and verbal communication for peer-to-peer discussions, appeals, and interdisciplinary collaboration.
Analytical skills to interpret utilization data and identify trends.
Proficiency with case management/utilization review platforms and standard office software.
Ability to manage competing priorities in a fast-paced clinical operations environment.

Nice To Haves

Certified Case Manager (CCM) or similar certification.
Bachelor's degree in Nursing, Health Administration, or related field (BSN preferred if RN).
Experience with managed care organizations, health plans, or third-party administrators.
Experience with utilization management software/platforms and referral management systems.

Responsibilities

Supervise, train, and mentor referral coordinators, case managers, and utilization review staff.
Manage daily workflow, staffing, and productivity to meet turnaround-time and service-level standards of referral and case management team.
Conduct performance evaluations, provide coaching, and manage disciplinary actions as needed.
Develop and maintain department policies, procedures, and workflows.
Apply and oversee the appropriate use of Milliman Care Guidelines (MCG) and other evidence-based criteria (e.g., InterQual) in reviewing referrals, authorizations, and continued stay/case management decisions.
Ensure medical necessity determinations are clinically sound, well-documented, and consistent with regulatory and accreditation standards (NCQA, URAC, CMS, state requirements).
Serve as a clinical resource for escalated or complex cases, peer-to-peer reviews, and appeals.
Identify utilization trends, over/under-utilization patterns, and opportunities for care coordination improvement.
Oversee case management activities to ensure appropriate transitions of care, discharge planning, and coordination of services.
Monitor caseloads and case complexity to ensure appropriate staff assignment and follow-up.
Partner with providers, facilities, and interdisciplinary teams to support member care plans.
Ensure department practices comply with applicable federal/state regulations, payer contracts, and accreditation requirements.
Participate in audits, quality reviews, and reporting related to utilization and case management metrics.
Support denial/appeal processes, ensuring appropriate clinical rationale and documentation.
Coordinate with medical directors, network/provider relations, quality, and claims teams on referral and utilization issues.
Report on team performance, utilization trends, and outcomes to leadership.