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.
New York, NY Salary Range
$95,000-$130,000 USD
Denver, CO Salary Range
$95,000-$130,000 USD
Charlotte, NC Salary Range
$95,000-$130,000 USD
All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
