3h ago
Utilization Management Director (RN)
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, appeals, and grievances. You'll manage the UM Department, act as a subject matter expert, and supervise staff to optimize members' healthcare outcomes.
Requirements
- Knowledge of utilization management principles and practices
- Knowledge of clinical nursing principles and practices
- Familiarity with Title 22, Knox Keene, Medicaid, Medicare, and related regulations
- Understanding of managed care UM documentation requirements for regulatory audits
- Registered Nurse (RN) licensure
Responsibilities
- Lead and shape the Utilization Management (UM) Strategy
- Oversee prior authorizations, concurrent review, medical claims review, appeals, and grievances
- Direct and manage the UM Department staff
- Provide direction and advice on department functions and business operations
- Act as subject matter expert on UM
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