utilization management manager

Centene

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
Remote Position: Will manage Prior Authorizations, Concurrent Review, and Retrospective Review Clinical Team for NICU Specialty. NICU experience required.
Position Purpose: Manages Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.<ul><li>
Manages prior authorization, concurrent review, and retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures</li><li>
Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives</li><li>
Develops, implements, and maintains compliance with utilization management policies and procedures</li><li>
Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership</li><li>
Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management</li><li>
Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers</li><li>
Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services</li><li>
Works with utilization management senior management team to provide updates and insights on team goals and objectives</li><li>
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards</li><li>
Assists utilization management senior leadership with onboarding, hiring, and training utilization management team members</li><li>
Leads and champions change within scope of responsibility</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5+ years of related experience.
2+ years supervisory experience preferred. 
Knowledge of utilization management principles preferred. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li></ul>
Pay Range: $87,000.00 - $161,300.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

Manager, Utilization Management

Humana

<div>
 
 Become a part of our caring community
 
 
 
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 
 
 
 As a Utilization Management Registered Nurse
 
 
 
 <ul>
 <li>
 You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
 </li>
 <li>
 Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
 </li>
 <li>
 You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
 </li>
 <li>
 You will communicate with providers, members, or other parties to facilitate care and treatment.
 </li>
 <li>
 You will help deliver coordinated care for our members
 </li>
 <li>
 You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <ul>
 <li>
 Must hold Compact Registered Nurse (RN) license in your state of residence
 </li>
 <li>
 Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
 </li>
 <li>
 Must be passionate about contributing to an organization focused on improving consumer experiences
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Previous experience in utilization management/utilization review for a health plan or acute care setting
 </li>
 <li>
 Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
 </li>
 <li>
 Experience working in a fully remote, metrics-focused role
 </li>
 <li>
 Experience as an MDS Coordinator or discharge planner in an acute care setting
 </li>
 <li>
 Experience as an RN for a Medicare Certified Home Health agency
 </li>
 <li>
 Health Plan or Medicare / Medicaid Experience
 </li>
 <li>
 Call center or triage experience
 </li>
 <li>
 BSN or bachelor's degree in a related field
 
 
 </li>
 </ul>
 Additional Information
 
 
 
 Work-at-Home Information
 
 
 
 To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
 
 
 <ul>
 <li>
 At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
 </li>
 <li>
 Satellite, cellular and microwave connection can be used only if approved by leadership.
 </li>
 <li>
 Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
 </li>
 <li>
 Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
 </li>
 <li>
 Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
 
 
 </li>
 </ul>
 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
 
 
 
 Scheduled Weekly Hours
 
 
 
 40
 
 
 
 Pay Range
 
 
 
 The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
 
 
 $71,100 - $97,800 per year
 
 
 This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
 
 
 
 Description Of Benefits
 
 
 
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
 
 
 
 About Us
 
 
 
 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
 
 
 
 Equal Opportunity Employer
 
 
 
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>

Utilization Management Registered Nurse

Trinity Health

Employment Type: 
Full time
 
Shift: 
Description: 
This position manages the activities of the Health Plan Clinical Services Team to ensure the achievement of department and company goals. The Clinical Manager will be responsible for overseeing the day-to-day clinical operations of the health plan, including patient care, staff management, and maintaining quality standards. Responsibilities include managing the performance of the team in accordance with the Upstream Health Plans Utilization and Quality Programs. Providing oversight and support to ensure overall outcomes and optimal Utilization Management and Quality performance.
 
1. Current licensure as a Registered Nurse in the State of California is required. Clinical professionals currently licensed outside the State of California will be provided six (6) months from date of hire to obtain equivalent California state licensure.
 2. Bachelor's Degree is required. Three years of Nursing Leadership experience may substitute for the Bachelor's Degree requirement.
 3. Two (2) years of management experience is required.
 4. Ability to communicate effectively with patients, families, and health care personnel and ability to lead, direct, and mentor personnel is required.
 5. Health Plan experience preferred.
 
Pay Range ($60.57 - $90.85)
 
Our Commitment
 
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Manager CVHP Clinical Operations

AltaMed Health Services

<div>Grow Healthy
If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn&rsquo;t just welcomed &ndash; it&rsquo;s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don&rsquo;t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it&rsquo;s a calling that drives us forward every day.
Job Overview
The Inpatient Case Management Manager oversees a team of nurses and support staff responsible for managing patients' care within the inpatient, SNF, and Home Health settings. The Manager in this role is a clinical professional with a registered nurse (RN) or licensed vocational nurse (LVN) license. Their responsibilities include direct supervision of inpatient, home health, and durable medical equipment (DME) nurses and support staff. This involves overseeing the inpatient leadership team, developing and implementing policies and procedures, analyzing day-to-day reporting, preparing for audits, providing mentorship to staff, and assisting with performance appraisals. The supervisor also acts as a subject matter expert on professional nursing and Inpatient regulations, representing the Inpatient team in various initiatives and client presentations while liaising with other business units to ensure appropriate discharge planning, work closely with the patient, their families, and the healthcare team to ensure a smooth and effective transition, considering the patient's medical needs and support requirements. The Manager leverages their expertise in care management and their knowledge of available resources to navigate challenging placement scenarios. This may involve collaborating with external providers, advocating for patients' needs, and working to find creative solutions to ensure that patients receive the most suitable care environment. The Manager plays a pivotal role in ensuring a seamless continuum of care for patients. They actively collaborate with various stakeholders, including physicians, social workers, insurance providers, and community organizations, to optimize care pathways and support services. By fostering strong relationships and effective communication, they can ensure a seamless continuum of care and access to necessary resources for patients as they move through different care settings.
Minimum Requirements
<ul><li>Current CA RN/LVN License required.
</li><li>Minimum of 7 years of relevant experience required.
</li><li>Minimum of 2 years of management experience as a team leader, supervisor, or project/program manager preferred.
</li><li>Requires health insurance/managed care experience (Commercial, Medicare, and Medi-Cal).
</li><li>Requires knowledge of Inpatient Case Management, Utilization Management, or Utilization Review
</li><li>A minimum requirement of a valid BLS certification or higher, following the American Heart Association (AHA) or the American Red Cross guidelines.
</li></ul>Compensation
$109,947.97 - $137,434.96 annually
Compensation Disclaimer
Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives.
Benefits &amp; Career Development
<ul><li>Medical, Dental and Vision insurance
</li><li>403(b) Retirement savings plans with employer matching contributions
</li><li>Flexible Spending Accounts
</li><li>Commuter Flexible Spending
</li><li>Career Advancement &amp; Development opportunities
</li><li>Paid Time Off &amp; Holidays
</li><li>Paid CME Days
</li><li>Malpractice insurance and tail coverage
</li><li>Tuition Reimbursement Program
</li><li>Corporate Employee Discounts
</li><li>Employee Referral Bonus Program
</li><li>Pet Care Insurance
</li></ul>Job Advertisement &amp; Application Compliance Statement
AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.</div>

Manager, Inpatient Case Management

<div><h1 class="jobSectionHeader">Become a part of our caring community 
</h1>
The Manager, Compliance Nursing reviews utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse. Reporting to the Clinical Strategy and Practice Director, you will work within specific guidelines and procedures; apply advanced technical knowledge to solve moderately complex problems; receive assignments in the form of objectives and determines approach, resources, schedules and goals.
Responsibilities include:<ul><li>
 Maintain NCQA accreditation and state contractual requirements with passage of UM standards, including timeliness of determinations, appropriateness of decision making and documentation in CGX and letters
</li><li>Ensures team meets all assigned work completion and submission deadlines (i.e letters, provider notification of decision, and reports); trends results to identify improvement opportunities</li><li>
Align procedures to improve associate productivity and quality to broaden role responsibilities for optimal outcomes</li><li>
Improve associate experience and member outcomes through innovation, identifying new ways of working using technology enhancements to streamline processes and create administrative efficiencies
</li><li>Requires cross departmental collaboration, and conducts briefings and area meetings, maintaining frequent contact with other managers across the market</li></ul><h1 class="jobSectionHeader"> 
Use your skills to make an impact 

</h1>Required Qualifications
o Active Licensed Registered Nurse (RN) in your state of residence without disciplinary action and ability to obtain multiple licenses.
o 2+ years of compliance experience
o 2 years team lead, coaching, subject matter expert, and/or project leadership experience
o 1 year of Utilization Management experience
o Proficiency using Microsoft Office Word, Excel, PowerPoint, 
Preferred Qualifications
o Associate's Degree
o Management experience
o Compact licensure
o Behavioral Health Utilization and/or Case Management experience which may include working knowledge of any or all the following, Interqual, MCG, ASAM
o NCQA UM Behavioral Health Accreditation Requirements
Additional Information<ul><li> Workstyle: Remote</li><li> Schedule: 40-hour work week Monday through Friday 9:00 to 6:00 PM or 8:30-5:30 Eastern Time</li><li> Travel: 1-2 times annually for onsite meetings</li></ul>
Interview Format
As part of our hiring process for this opportunity, we will use an interviewing technology called HireVue to enhance our hiring. HireVue allows us to quickly connect and gain valuable information from you about your relevant experience at a time that is best for your schedule.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. 

$86,300 - $118,700 per year 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 04-17-2026<h1 class="jobSectionHeader"> 

About us 
</h1>
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 
 
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.</div>

Manager, Compliance Nurse

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