Manager, Referral and Patient Care Management

Department: Clinical Operations / Utilization Management

Reports To:

FLSA Status: Exempt

Position Summary

The Manager, Referral and Case Management/Utilization Review is responsible for leading the day-to-day operations of the referral processing and case management/utilization review team. This role ensures timely, clinically appropriate, and compliant decisions on referrals, prior authorizations, and ongoing case management activities. The Manager oversees staff performance, applies evidence-based clinical criteria (including Milliman Care Guidelines/MCG), and works cross-functionally to support appropriate utilization of healthcare resources, regulatory compliance, and quality outcomes.

Key Responsibilities

Team Leadership & Operations
• Supervise, train, and mentor referral coordinators, case managers, and utilization review staff.
• Manage daily workflow, staffing, and productivity to meet turnaround-time and service-level standards of referral and case management team.
• Conduct performance evaluations, provide coaching, and manage disciplinary actions as needed.
• Develop and maintain department policies, procedures, and workflows.

Clinical Utilization Management
• Apply and oversee the appropriate use of Milliman Care Guidelines (MCG) and other evidence-based criteria (e.g., InterQual) in reviewing referrals, authorizations, and continued stay/case management decisions.
• Ensure medical necessity determinations are clinically sound, well-documented, and consistent with regulatory and accreditation standards (NCQA, URAC, CMS, state requirements).
• Serve as a clinical resource for escalated or complex cases, peer-to-peer reviews, and appeals.
• Identify utilization trends, over/under-utilization patterns, and opportunities for care coordination improvement.

Case Management Oversight
• Oversee case management activities to ensure appropriate transitions of care, discharge planning, and coordination of services.
• Monitor caseloads and case complexity to ensure appropriate staff assignment and follow-up.
• Partner with providers, facilities, and interdisciplinary teams to support member care plans.

Compliance & Quality
• Ensure department practices comply with applicable federal/state regulations, payer contracts, and accreditation requirements.
• Participate in audits, quality reviews, and reporting related to utilization and case management metrics.
• Support denial/appeal processes, ensuring appropriate clinical rationale and documentation.

Cross-Functional Collaboration
• Coordinate with medical directors, network/provider relations, quality, and claims teams on referral and utilization issues.
• Report on team performance, utilization trends, and outcomes to leadership.

Required Qualifications
• Active, unrestricted clinical license required: RN (Registered Nurse) strongly preferred; other clinical licensure (e.g., LPN with case management experience, LCSW) may be considered depending on organizational scope.
• Minimum 3-5 years of experience in utilization review, case management, or referral management within a managed care, health plan, or clinical setting.
• Minimum 1-2 years of supervisory or team lead experience.
• Demonstrated working knowledge and hands-on experience applying Milliman Care Guidelines (MCG) or equivalent nationally recognized utilization criteria (e.g., InterQual).
• Strong understanding of medical necessity review, prior authorization, concurrent review, and discharge planning processes.
• Familiarity with regulatory/accreditation standards (CMS, NCQA, URAC, state Medicaid/Medicare requirements) as applicable.

Preferred Qualifications
• Certified Case Manager (CCM) or similar certification.
• Bachelor's degree in Nursing, Health Administration, or related field (BSN preferred if RN).
• Experience with managed care organizations, health plans, or third-party administrators.
• Experience with utilization management software/platforms and referral management systems.

Skills & Competencies
• Strong clinical judgment and decision-making under regulatory/timeliness pressure.
• Leadership and team management skills, including performance management and coaching.
• Excellent written and verbal communication for peer-to-peer discussions, appeals, and interdisciplinary collaboration.
• Analytical skills to interpret utilization data and identify trends.
• Proficiency with case management/utilization review platforms and standard office software.
• Ability to manage competing priorities in a fast-paced clinical operations environment.

Working Conditions
• Primarily office-based or remote, depending on organizational policy.
• May require occasional availability for urgent clinical reviews outside standard hours.