Manager, Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Supervise all activities related to utilization management to ensure service consistency and achievement of utilization goals.

• Coordinate and oversee the pre-determination process for both medical and dental services.

• Ensure the consistent application of authorization criteria and conduct appropriate clinical reviews for adverse decisions.

• Develop integrated service delivery systems and manage utilization management data and processes.

• Administer benefits in accordance with state regulations, NCQA and/or URAC standards, and CareSource policies.

• Review and refine workflows to enhance operational efficiencies.

• Monitor productivity levels and utilization trends.

• Oversee Continuous Quality Improvement (CQI) activities, audits, and gather staff feedback.

• Report on utilization management regulatory requirements and ensure compliance.

• Maintain reporting and trend data for utilization management.

• Analyze the effects of under- and over-utilization on member quality of care and overall outcomes.

• Develop, sustain, and update departmental policies and procedures.

• Conduct audits of predetermination requests, documentation, and interrater reliability.

• Collaborate with other departments for research and intervention initiatives.

• Execute additional job-related tasks as directed.

⛳️ Requirements

• An Associate’s Degree in Nursing is mandatory; a Bachelor of Science in Nursing (BSN) is preferred.

• A minimum of five (5) years of clinical experience is required.

• At least five (5) years of experience in case management, utilization management, and/or quality improvement is necessary.

• Two years of experience in utilization management is preferred.

• Experience in managed care is advantageous.

• Basic proficiency in Excel, Word, and PowerPoint is needed.

• Experience with data analysis and trending is required.

• Familiarity with utilization management standards and practices is essential.

• Experience in management and prior supervisory skills are required.

• Ability to work both independently and collaboratively within a team environment is crucial.

• Familiarity with the healthcare industry is expected.

• Training and teaching skills are preferred.

• Strategic management skills are required.

• Negotiation skills and experience are necessary.

• Technical writing skills are essential.

• Leadership experience and skills are required.

• A current, unrestricted license as a Registered Nurse (RN) in the state of practice is mandatory.

🏝️ Benefits

• Performance-based bonus tied to both company and individual achievements.

• A comprehensive and substantial total rewards package.

• Support for the overall well-being of employees.