JOB SUMMARY

The Manager of Utilization Management (UM) is responsible for overseeing and directing the organization’s utilization management program to ensure appropriate use of healthcare services, regulatory compliance, and high-quality patient care outcomes.

Under the direction of senior leadership, the UM Manager supervises daily UM operations, including prospective, concurrent, and   retrospective review activities, while ensuring adherence to CMS, DMHC, and health plan requirements. This role provides leadership to UM staff, supports clinical decision-making processes, ensures timely authorization determinations, and promotes efficient healthcare resource utilization through effective team management, process improvement, and cross-functional collaboration.

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: Associate’s degree or completion of Vocational Nursing Program.

Preferred: Bachelor’s Degree in Nursing, Healthcare Administration, or related field.

Experience 

Minimum: At least five years of experience in utilization management, case management, or managed care and at least one year of leadership or supervisory experience.

Preferred: Clinical nursing experience. Experience in a health plan, MSO, IPA, or managed care environment. Experience with Medicare Advantage and Medi-Cal populations. Experience with InterQual, MCG, or similar criteria. Familiarity with EZ-Cap, EZ-Net, DocStar, or similar systems. Knowledge of ICD-10, CPT, and HCPCS coding.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

Current California Licensed Vocational Nurse (LVN) license in good standing and Basic Life Support (BLS) certification preferred

Skills, Knowledge & Abilities

· Strong knowledge of utilization management principles and medical necessity criteria 

· In-depth understanding of CMS, DMHC, and health plan regulations

· Leadership, coaching, and team development skills 

· Strong analytical, problem-solving, and decision-making abilities 

· Ability to manage multiple priorities in a fast-paced environment 

· Excellent written and verbal communication skills 

· Proficiency with EMR systems and UM platforms 

· Strong organizational and time management skills

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job.  Work is primarily performed in an office or remote environment and involves prolonged sitting while reviewing medical records and documentation. The position requires frequent use of a computer, telephone, and electronic medical record systems. Occasional standing, walking, and light lifting of materials up to approximately 20 pounds may be required. The role requires the ability to review detailed clinical information, maintain concentration for extended periods, manage multiple priorities in a fast-paced environment, and communicate effectively with providers, staff, and external partners.