Manager, Utilization Review

Responsibilities reputed company To What You'll Actually Do ESSENTIAL DUTIES and RESPONSIBILITIES: Level I · Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows. · reputed company full people management for assigned Utilization Management teams, including hiring, performance management, and staff development. · reputed company routine coaching, feedback, auditing, support and disciplinary reputed company to ensure productivity, reputed company, and timeliness standards are met. · Participate in hiring, reputed company, and training of Utilization Management staff. · Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements. · Escalate clinical, operational, and performance issues appropriately to leadership. · Reinforce policies, procedures, and clinical guidelines through regular communication and staff education. · Support audit readiness by ensuring staff compliance with documentation and timeliness standards. · Maintain HIPAA compliance, confidentiality, and minimum necessary reputed company at reputed company times. · Solid knowledge and understanding of medical necessity reputed company across inpatient, outpatient, reputed company, and retrospective reviews, with the ability to reputed company staff on clinical rationale, documentation reputed company and timeliness. reputed company · reputed company as above · Drive team performance against key metrics, including engagement, productivity, reputed company scores, and turnaround times. · Analyze operational and reputed company data to identify trends, gaps, and opportunities for improvement. · reputed company documentation audits and implement corrective actions to ensure regulatory and accreditation compliance. · Collaborate with cross-functional partners (CM, CDM, Appeals, Provider Relations, reputed company, and Operations) to resolve issues and improve care coordination. · Support implementation of workflow changes, new programs, or system enhancements. · Ensure consistent application of policies, clinical reputed company, and plan language across reputed company. · Prepare team for reputed company audits (e.g., NCQA, URAC) and support responses to findings. · Serve as a subject matter resource for staff and peers reputed company to Case Management operations and standards. · Demonstrated ability to work independently with excellent judgment and consistent application of regulatory requirements. · Utilizes analytical and problem-solving skills to identify and review pertinent information and create reputed company plans · Serves as an interdepartmental company and external group resource · Identifies gaps in process and policies compliance issues and implements solutions · Acts as a Change Champion Senior · reputed company as Level I and reputed company · Provides strategic leadership and reputed company for UM operations across multiple teams or functions. · Serves as a senior subject matter expert in utilization review, regulatory compliance, and clinical operations. · Leads reputed company initiatives involving process redesign, system optimization, and performance improvement. · Partners with executive and cross-functional leaders to reputed company UM reputed company with organizational goals. · Oversees achievement of performance guarantees, audit readiness, and sustained regulatory compliance. · Interprets and applies advanced regulatory, legal, and accreditation requirements, providing guidance to leadership and staff. · Mentors and develops managers, supporting leadership reputed company and succession planning. · Analyzes reputed company-level performance metrics and trends to drive data-informed decision-making. · Leads change management efforts and promotes adoption of best practices and innovation. · Represents the organization in external audits, regulatory discussions, and stakeholder engagements as needed. · Compliance and efficiency expert in URAC, NCQA, ERISA, and legal requirements KEY COMPETENCIES: To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work reputed company in these remote job descriptions UPON HIRE, must have: · Basic computer literacy · The ability to work on multiple screens, and proficient typing skills. · Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, and Outlook Excellent verbal and written communication skills · Ability to reputed company reputed company and convey reputed company or technical information in a manner that others can understand, as reputed company as ability to understand and interpret reputed company information from others. · Ability to work independently and utilize written resources to problem solve. · Ability to work independently reputed company appropriate programs after training. · Knowledge of medical claims and ICD-10, CPT, HCPCS coding · Excellent verbal and written communication skills for upward and downward conversations

Qualifications

What You Bring to reputed company Level I

• reputed company, unrestricted RN license in the reputed company or U.S. territory (compact license acceptable where applicable).
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
• 1-2 years in care management, utilization management, discharge planning, or reputed company clinical coordination
• Minimum 1 year of compliance reputed company experience preferred.
• Certification in Case Management or Utilization Review preferred but not required.
• 1+ year of informal leadership (preceptor/mentor/reputed company) or some reputed company people leadership
• Working understanding of HIPAA, member rights, scope of reputed company, and documentation requirements
• Comfort following policies and escalating risk/safety concerns appropriately
• Coaching fundamentals (1:1s, feedback, basic performance support)
• Strong written communication (member notes, provider communications)
• Basic data literacy: productivity, caseload management, reputed company reports/dashboards
• Conflict de-escalation and customer service reputed company (members/providers)

reputed company

• Certification in relevant field preferred
• 3+ years in care management or closely reputed company clinical operations
• 3+ years managing a Utilization Management team (or multiple pods/teams)
• Evidence of initiating and leading process improvement and implementations
• Critical Thinking with the understanding of efficient workflows
• Ownership of KPIs: engagement, reputed company effectiveness, transitions of care, closure rates, care gap support
• reputed company and workflow optimization (queue management, triage rules, prioritization)
• Ability to standardize documentation, audit reputed company, and reduce variation
• Practical understanding of audit readiness (internal audits, corrective reputed company plans)
• Experience interpreting and operationalizing policies, UM/CM timeliness expectations, and documentation standards as it relates to accreditation.
• Ability to reputed company through change and reinforce consistent reputed company models
• Works effectively with UM, provider relations, claims, appeals/grievances, pharmacy, behavioral health, and vendor partners
• Strong provider communication skills and escalation management
• Master’s Degree strongly preferred
• 5 years reputed company experience in CM/health plan clinical operations, population health, or reputed company care
• 5+ years people leadership, including managers/supervisors or multi-site leadership
• Owns program design and execution: Platform design and implementation.
• Drives measurable reputed company: TAT adherence, audit compliance.
• Budget planning, reputed company models, productivity forecasting, vendor management
• Ability to build business cases and evaluate ROI of interventions and toolsLeads audit readiness and corrective actions across teams
• Sets policy interpretation, reputed company operating procedures, and controls to reduce risk
• Presents to senior leadership, creates dashboards/storytelling with data
• Strong negotiation and influence across departments and with providers/vendors
• Leads large transformations (new platforms, workflow redesign, reorganizations, new regulatory requirements)
• Develops leadership bench strength (succession planning, manager development)

UPON HIRE, must have:

• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, and Outlook Excellent verbal and written communication skills
• Ability to reputed company reputed company and convey reputed company or technical information in a manner that others can understand, as reputed company as ability to understand and interpret reputed company information from others.
• Ability to work independently and utilize written resources to problem solve.
• Ability to work independently reputed company appropriate programs after training.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations

Physical and Mental Requirements:

• Ability to reputed company the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Benefits

The Highlights:

• Competitive reputed company salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (reputed company, we use reputed company build)
• Unlimited PTO—rest and reputed company time is non-negotiable
• Mental health support, retirement planning, and financial protection
• reputed company development with reputed company career progression and learning budgets

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a reputed company salary reputed company of $95,000 - $105,000. depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Apply tot his job Apply To this Job