Senior Manager of Utilization Management & Case Management

Prime Healthcare Management Inc•Ontario, CA

1d•$110,968 - $173,035

About The Position

The Senior Manager of Utilization Management & Case Management provides strategic leadership and operational oversight for core clinical operations, including outpatient prior authorization, inpatient concurrent review, case management, and medical appeals. The role ensures high-quality, cost-effective care aligned with regulatory standards—including NCQA, CMS, and state mandates—and health plan policies, while leading a high-performing team of clinical and non-clinical professionals.

Requirements

Five or more years of clinical nursing or healthcare experience.
Three to five years of progressive leadership or management experience within a managed care organization, health plan, or insurance setting.
Deep knowledge of Medicare, Medicaid, Commercial, and Marketplace insurance regulations.
Proficiency with health plan software, such as MCG, InterQual, and CMS.
Strong data analytics skills.

Nice To Haves

Active, unrestricted Licensed Vocational Nurse (LVN) license in the state of operation; highly preferred.
Lean or advanced clinical degrees, such as RN, BSN, MSN, or LCSW.
Certified Case Manager (CCM) or Certified Professional in Utilization Review (CPUR) designation, or relevant experience managing teams.

Responsibilities

Provide strategic leadership and operational oversight for outpatient prior authorization, inpatient concurrent review, case management, and medical appeals.
Ensure delivery of high-quality, cost-effective care that aligns with regulatory standards and health plan policies.
Lead a high-performing team of clinical and non-clinical professionals.
Translate operational metrics into actionable clinical strategies.