Manager, Utilization Management

Manager, Utilization Management

Commonwealth Care Alliance's (CCA) Utilization Management (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of CCA's benefits plan. The Manager, Utilization Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally authorized services. This position has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

Essential Duties & Responsibilities:

• Oversees clinical decision review for services requiring prior authorization in a variety of clinical areas.
• Maintains and optimizes Standard Operating Procedures related to authorization review.
• Ensures timely and appropriate determinations of medical necessity.
• Leads preparation for internal and external audits.
• Hires, trains, and mentors UM staff.
• Acts as liaison with medical director, provider relations, case management, and quality teams.
• Manages the process for escalated reviews.
• Provides guidance to UM Nurses and clinical teams.
• Liaises with clinical teams and re-insurer on high-cost cases.
• Ensures that department and organizational policies and procedures are met.
• Tracks and monitors team's performance.
• Investigate and resolve member complaints and grievances.
• Additional duties as requested.

Working Conditions:

• Standard office conditions.
• Office environment, some travel to clinical practices may be required.

Required Education (must have):

• Associate degree in Nursing

Required Experience (must have):

• 3-5 years utilization management experience
• 3+ years' experience working in a health plan, specifically with utilization management.

Required Knowledge, Skills & Abilities (must have):

• Expertise in managing utilization review processes.
• Demonstrated ability to establish and manage performance and outcome metrics.
• Excellent collaboration and communication skills.
• In-depth knowledge of medical necessity criteria.
• Ability to lead audit readiness efforts.
• Flexibility and understanding of individualized care plans.
• Proficient in using data to drive decisions.
• Strong project management skills.
• Ability to establish and maintain positive work relationships.
• Proven skills and judgment necessary for independent decision-making.
• Excellent organizational, time-management, and problem-solving skills.
• Strong management skills.
• Ability to influence decision making.

Required Language (must have):

• English

Compensation Range/Target: $115,715 - $173,573

Commonwealth Care Alliance takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level.

EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.