Description

You will oversee clinical operations for delegated utilization and care management across multiple health plan clients in California's Medi-Cal and Medicaid markets. This remote role involves ensuring consistent application of clinical review criteria, managing daily UM workflows, and maintaining performance standards for authorizations, denials, and appeals.

Requirements

• Master's degree in nursing, business, or related healthcare field preferred
• Minimum 10 years experience in population health management
• Experience managing a team in a remote work environment
• Active and unrestricted Registered Nurse (RN) license in California
• Experience in program development and management

Responsibilities

• Ensure consistent application of clinical review criteria in authorization and review processes
• Support daily UM workflows including case review, turnaround time management, and staffing models
• Participate in internal and health plan audits and maintain UM policies and procedures
• Partner with medical directors to resolve complex cases and appeals
• Identify trends in overutilization, underutilization, and inappropriate site-of-care decisions