3h ago

Utilization Management Director (RN)

Mariposa County, California; Merced County, California; Monterey County, California; San Benito County, California; Santa Cruz County, California; Remote, California
full-timedirector HybridHealth Insurance

Description

You will lead and shape the Utilization Management Strategy for the Alliance, overseeing prior authorizations, concurrent review, medical claims review, and appeals. You will manage the UM Department, act as a subject matter expert, and supervise staff to optimize healthcare outcomes for members.

Requirements

  • Registered Nurse (RN) license
  • Knowledge of utilization management principles and practices
  • Knowledge of Title 22, Knox Keene, Medicaid, Medicare, and related regulations
  • Knowledge of managed care UM documentation requirements
  • Strong clinical leadership and strategic oversight skills

Responsibilities

  • Lead and shape Utilization Management strategy
  • Oversee prior authorizations, concurrent review, medical claims review, appeals and grievance
  • Direct the UM Department and act as subject matter expert
  • Manage and supervise UM Department staff
  • Ensure compliance with regulatory requirements and audit readiness
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