Supervisor, Utilization Management (Hybrid Remote, Must have California LVN / RN License)

Alignment Health

59d•Hybrid

About The Position

Alignment Health is seeking a Supervisor, Utilization Management to manage the UM Department and oversee preservice processes. This role involves directly supervising licensed and coordinator staff performing UM duties, promoting quality patient care outcomes, and ensuring appropriate resource management. The position is also responsible for auditing and completing reports to meet CMS compliance requirements. This is an exempt leadership role supporting a clinical team that operates Monday–Friday during Pacific Time business hours. The supervisor is expected to maintain regular availability during these hours to provide leadership oversight, support clinical operations, and partner with interdisciplinary teams. Weekend leadership coverage is shared between the supervisor and director on a rotating basis. This position is primarily remote, with occasional in-person attendance at the Orange, CA headquarters required for leadership meetings and team collaboration. Candidates located outside of California should expect periodic travel to the Orange office, with reimbursed travel expenses.

Requirements

Minimum (1) year recent and related supervisor experience
Minimum (2) years related experience in a managed care setting, which includes inpatient and preservice utilization management
Successful completion of an accredited Registered Nursing Program or Vocational Nursing program.
Knowledge of Medicare Managed Care Manuals and CMS regulatory requirements
Proficiency in Word, Excel, Microsoft Outlook
Experience with the application of clinical criteria (i.e., MCG, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.)
Able to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Effective written and oral communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors
Able to perform mathematical calculations and calculate simple statistics correctly
Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution
Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment
Comprehend and analyze statistical reports
Must have and maintain an active, valid, and unrestricted RN / LVN license in California (Non-Compact)
Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.

Nice To Haves

CCM or ABQAURP certification.

Responsibilities

Ensure UM clinical staff members perform Pre-Service reviews on submitted requests within CMS and Alignment Health turnaround timeframes and according to regulatory and Health Plan guidelines.
Ensure staff use sound clinical judgment to make final determinations, utilizing Alignment Health approved clinical criteria according to hierarchy.
Ensure staff follow pre-service workflows.
Ensure staff put the member first while managing benefits appropriately, considering the individual’s unique needs.
Ensure assigned staff comply with CMS and Alignment Health interdepartmental processes when participating in the Medical Claims Review process.
Ensure staff coordinate care internally and externally.
Monitor documentation to ensure alignment with Health Plan and department policies, protocols, and standard operating procedures.
Collect, evaluate, and report data and activities as applicable within the UM program (e.g., monthly, quarterly, and annual reports).
Perform department quality and vendor audits to assess case timeliness and ensure compliance.
Collaborate with primary care physicians, specialty care physicians, mental health professionals, home health professionals, and other healthcare professionals regarding escalated needs.
Establish and maintain effective interpersonal relationships with staff at all levels, providers, and internal departments.
Attend meetings with vendors and/or other departments regarding UM policies and procedures.
Maintain confidentiality of information between and among healthcare professionals.
Perform UM reviews when required, including handling escalated cases.
Implement Alignment internal and CMS-specific programs (e.g., Medical Claims Review).
Develop, review, and revise as necessary policies, procedures, protocols, and processes related to Pre-Service and Claims UM.
Oversee assigned staff, including recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
Recruit, select, onboard, train, mentor, and coach UM clinicians and coordinators to ensure compliance with internal and regulatory guidelines.
Assign workload; plan, monitor, and appraise work results.
Conduct 1:1 coaching (coach, counsel, and discipline) with employees and create, implement, and track corrective action plans and Objectives and Key Results (OKRs).
Manage time-off requests, scheduling, and overtime utilization.
Create and maintain an environment that inspires and encourages the growth and engagement of team members.