Senior Manager of Utilization Management & Case Management

The Senior Manager of Utilization Management & Case Management provides strategic leadership and operational oversight for core clinical operations, including outpatient prior authorization, inpatient concurrent review, case management, and medical appeals. This role ensures the delivery of high-quality, cost-effective care that aligns with regulatory standards (NCQA, CMS, state mandates) and health plan policies while leading a high-performing team of clinical and non-clinical professionals

Required qualifications:

1. Active, unrestricted Licensed Vocational Nurse (LVN) license in the state of operation (highly preferred). Lean or advanced clinical degrees (e.g., RN, BSN, MSN, LCSW) are a plus.

2. Certified Case Manager (CCM) or Certified Professional in Utilization Review (CPUR) designation is highly desirable or relevant experience managing teams.

3. 5+ years of clinical nursing or healthcare experience.

4. 3-5 years of progressive leadership/management experience within a managed care organization (MCO), health plan, or insurance setting.

5. Deep knowledge of Medicare, Medicaid, Commercial, and Marketplace insurance regulations.

6. Proficiency with health plan software (e.g., MCG, InterQual, CMS).

7. Strong data analytics skills to translate operational metrics into actionable clinical strategies.

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.  Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.  A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $110,968.00 to $173,035.20 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.