Utilization Management Director (RN)

Central California Alliance for Health (Remote)•Hollister, CA

2d•Hybrid

About The Position

We have an opportunity to join the Alliance as the Utilization Management Director (RN) leading the Utilization Management Department. This is a hybrid position with the expectation to work in our service area(s) 1-2 days per month. Our mission is to optimize members’ healthcare outcomes through evidenced-based clinical management, stewardship, and collaboration with provider and community partners. The IDEAL CANDIDATE A strong clinical leader with deep UM expertise who brings sound judgment, regulatory awareness, and a commitment to mission‑driven decision‑making. Relationship‑centered and impact‑minded, able to balance oversight of the Utilization Management department with a collaborative approach that maintains trust across internal teams and external partners. Strategic, change‑ready, and operationally adept, guiding teams through evolving priorities, articulating organizational shifts with clarity, and advancing process improvements and cross‑functional projects that strengthen UM operations. A transparent communicator and mentor, skilled at prioritizing, supporting team growth, modeling accountability, and sustaining momentum while adapting thoughtfully as work evolves. A bridge‑builder who sees the big picture, collaborating across functions, presenting confidently, and fostering alignment and cohesion in a fast-moving environment.

Requirements

Knowledge of: The principles and practices of utilization management
The principles and practices of clinical nursing
Title 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulations
The principles and practices of managed care
UM documentation requirements necessary to satisfy regulatory audits
Ability to: Direct, manage, supervise, mentor, train and evaluate the work of staff
Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
Develop, plan, organize and direct programs and activities that are complex in nature and regional in scope
To identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activities
Demonstrate a collaborative management style, build rapport, and effectively manage internal and external business relationships including with members of the medical community, community agencies, and board members
Education and Experience: Current unrestricted license as a Registered Nurse issued by the state of California
Bachelor’s degree in Nursing
A minimum of ten years of utilization management experience which included a minimum of five years of experience in a managed care environment and three years of staff management experience (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

Responsibilities

Leads and shapes the Utilization Management (UM) Strategy for the Alliance while providing management oversight in implementing, directing and monitoring the Utilization Management Department functions, including prior authorizations, concurrent review, medical claims review, appeals and grievance
Directs the Utilization Management Department, acts as a subject matter expert, and provides direction and advice on the Department’s functions and overall business operations
Directs, manages and supervises Utilization Management Department staff