Description

You will oversee the strategy, operations, and performance of Delegated Utilization Management and Care Management programs across multiple health plan clients in California Medi-Cal and Medicaid markets, ensuring healthcare services are medically necessary, cost-effective, and compliant with regulatory standards.

Requirements

• Bachelor’s Degree in business, healthcare administration, nursing, or related field
• Minimum 10 years MSO operations experience with at least 5 years in national/regional management role
• Experience in change management and process improvement
• Strong clinical leadership and communication skills
• Deep clinical acumen with expertise in utilization review and management

Responsibilities

• Drive quality, efficiency, and consistency using benchmarks
• Lead and develop UM/CM Directors
• Oversee daily UM and CM operations including prior authorization, concurrent review, retrospective review, and care coordination
• Ensure compliance with federal, state, health plan, and NCQA requirements
• Integrate care management into physician workflows