Manager, Utilization Review

Responsibilities

Ready To What You'll Actually Do ESSENTIAL DUTIES and RESPONSIBILITIES: Level I · Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows. · Provide full people management for assigned Utilization Management teams, including hiring, performance management, and staff development. · Provide routine coaching, feedback, auditing, support and disciplinary action to ensure productivity, quality, and timeliness standards are met. · Participate in hiring, onboarding, and training of Utilization Management staff. · Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements. · Escalate clinical, operational, and performance issues appropriately to leadership. · Reinforce policies, procedures, and clinical guidelines through regular communication and staff education. · Support audit readiness by ensuring staff compliance with documentation and timeliness standards. · Maintain HIPAA compliance, confidentiality, and minimum necessary access at all times. · Solid knowledge and understanding of medical necessity criteria across inpatient, outpatient, concurrent, and retrospective reviews, with the ability to coach staff on clinical rationale, documentation quality and timeliness. Level II · Same as above · Drive team performance against key metrics, including engagement, productivity, quality scores, and turnaround times. · Analyze operational and quality data to identify trends, gaps, and opportunities for improvement. · Lead documentation audits and implement corrective actions to ensure regulatory and accreditation compliance. · Collaborate with cross-functional partners (CM, CDM, Appeals, Provider Relations, Quality, and Operations) to resolve issues and improve care coordination. · Support implementation of workflow changes, new programs, or system enhancements. · Ensure consistent application of policies, clinical criteria, and plan language across the team. · Prepare team for internal and external audits (e.g., NCQA, URAC) and support responses to findings. · Serve as a subject matter resource for staff and peers related to Case Management operations and standards. · Demonstrated ability to work independently with excellent judgment and consistent application of regulatory requirements. · Utilizes analytical and problem-solving skills to identify and review pertinent information and create action plans · Serves as an interdepartmental company and external group resource · Identifies gaps in process and policies compliance issues and implements solutions · Acts as a Change Champion Senior · Same as Level I and Level II · Provides strategic leadership and oversight for UM operations across multiple teams or functions. · Serves as a senior subject matter expert in utilization review, regulatory compliance, and clinical operations. · Leads complex initiatives involving process redesign, system optimization, and performance improvement. · Partners with executive and cross-functional leaders to align UM strategy with organizational goals. · Oversees achievement of performance guarantees, audit readiness, and sustained regulatory compliance. · Interprets and applies advanced regulatory, legal, and accreditation requirements, providing guidance to leadership and staff. · Mentors and develops managers, supporting leadership growth and succession planning. · Analyzes enterprise-level performance metrics and trends to drive data-informed decision-making. · Leads change management efforts and promotes adoption of best practices and innovation. · Represents the organization in external audits, regulatory discussions, and stakeholder engagements as needed. · Compliance and efficiency expert in URAC, NCQA, ERISA, and legal requirements KEY COMPETENCIES: To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions UPON HIRE, must have: · Basic computer literacy · The ability to work on multiple screens, and proficient typing skills. · Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills · Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. · Ability to work independently and utilize written resources to problem solve. · Ability to work independently within appropriate programs after training. · Knowledge of medical claims and ICD-10, CPT, HCPCS coding · Excellent verbal and written communication skills for upward and downward conversations

Qualifications

What You Bring to Our Team Level I

• Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable).
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
• 1-2 years in care management, utilization management, discharge planning, or related clinical coordination
• Minimum 1 year of compliance related experience preferred.
• Certification in Case Management or Utilization Review preferred but not required.
• 1+ year of informal leadership (preceptor/mentor/lead) or some direct people leadership
• Working understanding of HIPAA, member rights, scope of practice, and documentation requirements
• Comfort following policies and escalating risk/safety concerns appropriately
• Coaching fundamentals (1:1s, feedback, basic performance support)
• Strong written communication (member notes, provider communications)
• Basic data literacy: productivity, caseload management, simple reports/dashboards
• Conflict de-escalation and customer service mindset (members/providers)

Level II

• Certification in relevant field preferred
• 3+ years in care management or closely related clinical operations
• 3+ years managing a Utilization Management team (or multiple pods/teams)
• Evidence of initiating and leading process improvement and implementations
• Critical Thinking with the understanding of efficient workflows
• Ownership of KPIs: engagement, outreach effectiveness, transitions of care, closure rates, care gap support
• Staffing and workflow optimization (queue management, triage rules, prioritization)
• Ability to standardize documentation, audit quality, and reduce variation
• Practical understanding of audit readiness (internal audits, corrective action plans)
• Experience interpreting and operationalizing policies, UM/CM timeliness expectations, and documentation standards as it relates to accreditation.
• Ability to lead through change and reinforce consistent practice models
• Works effectively with UM, provider relations, claims, appeals/grievances, pharmacy, behavioral health, and vendor partners
• Strong provider communication skills and escalation management
• Master’s Degree strongly preferred
• 5 years progressive experience in CM/health plan clinical operations, population health, or complex care
• 5+ years people leadership, including managers/supervisors or multi-site leadership
• Owns program design and execution: Platform design and implementation.
• Drives measurable outcomes: TAT adherence, audit compliance.
• Budget planning, staffing models, productivity forecasting, vendor management
• Ability to build business cases and evaluate ROI of interventions and toolsLeads audit readiness and corrective actions across teams
• Sets policy interpretation, standard operating procedures, and controls to reduce risk
• Presents to senior leadership, creates dashboards/storytelling with data
• Strong negotiation and influence across departments and with providers/vendors
• Leads large transformations (new platforms, workflow redesign, reorganizations, new regulatory requirements)
• Develops leadership bench strength (succession planning, manager development)

UPON HIRE, must have:

• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• Ability to work independently within appropriate programs after training.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations

Physical and Mental Requirements:

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Benefits

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Unlimited PTO—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $95,000 - $105,000. depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Apply tot his job Apply To this Job