Description

You will oversee clinical capabilities for utilization and care management across multiple health plan clients, ensuring adherence to regulatory standards and leading daily operations. Your role involves direct participation in clinical reviews, maintaining performance standards, and collaborating with teams to improve care coordination.

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.

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, maintaining 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.