Tech Stack

Description

You will lead UM operations across multiple IPAs, ensuring regulatory compliance and operational efficiency. You'll manage a team of 5–10 professionals, serve as the primary health plan liaison, oversee authorizations and audits, and partner with the AI Operations team to implement automations and process improvements.

Requirements

• Minimum 10 years of experience in Utilization Management, Managed Care, or IPA/MSO operations
• Deep expertise in regulatory requirements governing delegated UM functions in California (preferred)
• Experience overseeing health plan audits, delegated oversight reporting, and ODAG logs (preferred)
• Demonstrated experience managing teams in a multi-IPA or delegated risk environment (preferred)
• Strong knowledge of authorization workflows, and medical necessity criteria (preferred)
• MCG Certified (preferred)
• Experience serving as a primary operational contact for health plans (preferred)
• Proficiency in platforms such as EZCap, EZNet, EMR systems, reporting tools (e.g., Crystal Reports), and health plan portals (preferred)
• Exceptional organizational, analytical, and process improvement skills
• Strong leadership presence with the ability to drive accountability and cross-functional collaboration
• Comfortable working onsite in Chino, CA

Responsibilities

• Provide strategic oversight of all UM operations across multiple IPAs, ensuring regulatory compliance and operational efficiency
• Lead, mentor, and manage a team of 5–10 UM professionals, setting performance standards and ensuring accountability
• Serve as the primary operational liaison for contracted health plans, responding to inquiries, performance concerns, reporting requirements, and escalations
• Oversee all UM-related health plan audits, coordinating preparation efforts and ensuring readiness, accuracy, and timely submission of materials
• Ensure adherence to regulatory timelines for authorizations and reporting (ODAG logs, timeliness reports, UMC/UMCIS reports)
• Oversee authorization workflows, queue management, escalation processes, and medical necessity review frameworks
• Maintain and update UM policies and procedures in alignment with regulatory and health plan requirements
• Partner with executive leadership to identify process improvements, system enhancements, and automation opportunities to scale MSO operations
• Create and maintain SOPs for all core workflows