Utilization Management Manager

This is a fully remote position, open to applicants in Connecticut, +1 more state.

📋 Description

• Lead, supervise, mentor, and enhance the skills of registered nurses and non-licensed clinical support personnel.

• Assess team performance, set expectations, and provide coaching, training, and ongoing education.

• Recognize operational challenges and implement corrective action plans alongside performance improvements.

• Oversee utilization management processes spanning Commercial, Medicare, and Medicaid business lines.

• Collaborate with the Medical Director to create Quality Improvement Activities and manage Delegation Agreements.

• Assess clinical treatment criteria and ensure staff receive adequate training in their application.

• Leverage data to evaluate outcomes, identify trends, monitor performance, and suggest areas for improvement.

• Develop and execute processes that promote positive member outcomes and responsible healthcare cost management.

• Ensure compliance with NCQA, MCRA, and other relevant regulatory standards.

• Manage vendor relationships and foster effective partnerships.

• Work in conjunction with Provider Relations, Healthcare Economics, Sales, Member Services, Claims, ASO, and other internal teams.

• Assist with project and product implementations while assessing new technologies and applications.

• Maintain the Health Services Operations Manual in collaboration with department leadership.

• Present updates, findings, and recommendations to executive leadership, management, and colleagues.

• Drive department involvement in the Manager-Led Problem Solving process.

⛳️ Requirements

• Bachelor's Degree in Nursing, required.

• Active RN License in Massachusetts, required.

• At least 5 years of progressively responsible experience in case management and/or utilization management.

• Proven leadership and negotiation skills.

• Experience in project management.

• Strong understanding of state licensure, regulatory requirements, and NCQA accreditation standards.

• Familiarity with data collection, analysis, and presentation techniques.

• Knowledge of Medicare and Medicaid benefits and regulatory requirements.

• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Access.

• Exceptional written, verbal, presentation, and problem-solving abilities.

• Capability to work independently, prioritize tasks, manage competing demands, and adapt to dynamic organizational needs.

• Nursing Informatics certification from the American Nurses Credentialing Center.

🏝️ Benefits

• Monday through Friday work schedule.

• No weekends required.

• No holiday work.

• Fully remote position.

• Occasional evening meetings.