Job Description

Your Role

The Utilization Management team reviews inpatient stays and prior authorization for our members and correctly applies the guidelines for nationally recognized levels of care for both our Medi-Cal and Medicare populations. The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for members. You will apply advanced clinical knowledge and proven management skills to organize work, coach staff, and manage risk. Your leadership helps drive consistent, high-quality utilization management outcomes.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work
In this role, you will:

• Establish operational objectives for department or functional area and participate with other managers to establish group objectives
• Be responsible for team, department, or functional area results in terms of planning, cost; in collaboration with department Director
• Participate in the development and implementation of the annual budget under the direction of Sr Manager / Director
• Ensure workflow procedures and guidelines are clearly documented and communicated
• Interpret or initiate changes in guidelines/policies/procedures
• Establish and manage operational and regulatory reports
• Ensure regulatory and accreditation standards are met for Medicare, and Medi-Cal lines of business
• Collaborate across functional departments to improve member outcomes
• Participate in regulatory and internal audits as applicable
• Support and facilitate staff meetings, clinical rounds, and weekly huddles

Qualifications

Your Knowledge and Experience

• Requires maintaining an active, unrestricted RN license in assigned states or the ability to obtain required state (in addition to primary state license) RN license within 90 days of hire
• Requires 7 years of prior relevant experience including 3 years of management experience gained as a team leader, supervisor or project/program manager
• Requires knowledge of regulatory requirements for government lines of business (Medi-Cal and Medicare)
• Bachelor of Science in Nursing or advanced degree preferred
• Demonstrated experience with basic management approaches such as work scheduling, prioritizing, coaching, process execution, work organization, inventory management, risk management and delegation
• Strong emotional intelligence skills
• Strong communication and computer navigation skills
• Strong teamwork and collaboration skills
• Strong critical thinking skills
• Independent motivation and strong work ethic

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About the Team

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.