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, appeals, and grievances. Your work ensures members receive evidence-based care while maintaining regulatory compliance and operational efficiency.
Requirements
- Registered Nurse (RN) license
- Knowledge of utilization management principles and practices
- Knowledge of Title 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulations
- Knowledge of managed care and UM documentation requirements for regulatory audits
Responsibilities
- Lead and shape the Utilization Management strategy for the Alliance
- Direct UM department functions including prior authorizations, concurrent review, medical claims review, appeals and grievance
- Serve as subject matter expert and provide direction on department operations
- Manage and supervise Utilization Management staff
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