Utilization Management Market Operations Manager, RN Preferred

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

📋 Description

• Oversee operational functions for Utilization Management and Appeals for designated lines of business.

• Create and uphold policies and standard operating procedures.

• Analyze team metrics and manage statutory reporting.

• Supervise committee reviews, audit preparations, presentations, and annual program obligations.

• Implement process controls to attain operational excellence.

• Collaborate with clinical leadership to resolve operational procedure discrepancies.

• Propel process enhancements utilizing continuous improvement frameworks.

• Administer policy and process modifications stemming from regulatory and compliance mandates.

• Provide education, mentorship, and training for staff and clinical leaders.

• Cultivate internal and external relationships to enhance standardization and collaboration.

• Establish and utilize outcome measurements to foster success.

• Develop future-state operating models.

• Manage opportunities for cross-divisional and cross-functional process enhancements.

• Supervise change management initiatives impacting the department.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• An Associate degree in Nursing or an advanced degree in Psychology is required.

• A minimum of five years of experience in Utilization Management or related operations is required.

• Experience in Managed Care is essential.

• Proficiency in analysis, data, and reporting is required.

• Proven leadership skills in change management and continuous improvement are necessary.

• Current, unrestricted Registered Nurse (RN) licensure or Licensed Psychologist license in the state of practice is mandatory.

• Competent in Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook, and Visio.

• Familiarity with NCQA and/or CMS accreditation and auditing standards is essential.

• Understanding of regulatory reporting, compliance requirements, and auditing procedures is required.

• Strong decision-making, problem-solving, critical-thinking, planning, and resolution abilities.

• Excellent oral, written, and interpersonal communication skills.

• Experience with quality improvement, performance enhancement, and operations.

• Capability to manage multiple competing priorities and collaborate with multidisciplinary departments.

• Ability to work independently as well as part of a team.

• Strong attention to detail and time management capabilities.

• Proficient in customer service and de-escalation techniques.

• Skilled in gathering and analyzing data to create actionable insights.

• Competence in reviewing and implementing evidence-based trends.

• Experience in accreditation, auditing, process improvement, quality control, or process standards is preferred.

• Six Sigma or project management certifications are advantageous.

• Residency in Nevada and possession of the required state license are necessary.

🏝️ Benefits

• Competitive base salary range of $83,000.00–$132,800.00 annually.

• Potential bonus linked to both company and individual performance.

• Comprehensive and substantial total rewards package.

• Support for employee well-being.