Manager, Medical Utilization and Care Management

Position Responsibilities:

• Provide oversight for vendors conducting utilization management, care management, and clinical operations activities.
• Oversee vendor execution of utilization reviews, including prospective, concurrent, and retrospective reviews, to ensure medical necessity and appropriate level of care determinations.
• Monitor vendor review of medical records and treatment plans to support appropriate service utilization, avoid unnecessary or duplicate services, and optimize reimbursement outcomes.
• Partner with the Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations.
• Provide oversight of vendor-managed prior authorization, peer-to-peer review, denial, appeal, and notification processes.
• Ensure vendors complete comprehensive biopsychosocial assessments and health risk assessments (HRAs) in accordance with program requirements.
• Oversee vendor-led care coordination across the continuum, including transitions of care and discharge planning.
• Provide oversight of vendor-administered chronic disease and complex case management programs.
• Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care.
• Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented.
• Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements.
• Coordinate with vendor interdisciplinary teams, including nurses, social workers, and care coordinators, to promote aligned clinical operations and member outcomes.
• Promote vendor-delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes.

Required Qualifications:

• Active unrestricted RN license (BSN preferred)
• 5+ years of experience in utilization management, care management, or case management
• 2+ years leadership experience
• Knowledge of medical necessity reviews, care coordination models, and payer systems

Preferred Qualifications:

• Certification (CCM, CMGT-BC, HCQM).
• Experience with Commercial, Medicare and Medicaid population.
• Experience working with Medical Directors, Vendors, and Health Systems.
• Knowledge of URAC/NCQA standards.