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 HybridHealthcare

Description

You will lead the Utilization Management Department, shaping strategy and overseeing prior authorizations, concurrent review, medical claims review, and appeals/grievance. This hybrid role requires working in the service area 1-2 days per month, with priority given to candidates living in Santa Cruz, Monterey, Merced, San Benito, or Mariposa counties.

Requirements

  • Knowledge of UM principles and practices
  • Knowledge of clinical nursing principles and practices
  • Knowledge of Title 22, Knox Keene, Medicaid, Medicare, and related regulations
  • Knowledge of managed care UM documentation requirements for regulatory audits

Responsibilities

  • Lead and shape the Utilization Management Strategy
  • Provide management oversight for prior authorizations, concurrent review, medical claims review, appeals and grievance
  • Direct the UM Department as subject matter expert
  • Direct, manage and supervise UM Department staff
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