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 (UM) strategy for the Alliance, overseeing prior authorizations, concurrent review, medical claims review, appeals, and grievances. You'll direct the UM Department and act as a subject matter expert, ensuring regulatory compliance and mission-driven care.

Requirements

  • Knowledge of principles and practices of utilization management
  • Knowledge of clinical nursing principles and practices
  • Knowledge of Title 22, Knox Keene, Medicaid, Medicare, entitlement programs
  • Knowledge of managed care UM documentation requirements for regulatory audits

Responsibilities

  • Leads and shapes the Utilization Management (UM) Strategy
  • Provides management oversight for prior authorizations, concurrent review, medical claims review, appeals and grievance
  • Directs the Utilization Management Department and acts as subject matter expert
  • Directs, manages and supervises UM Department staff
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