Supervisor, Utilization Management

The Clinical Utilization Management (UM) Supervisor is responsible for overseeing daily operations of the Utilization Management team to ensure timely, accurate, and appropriate clinical decision-making and case management. This role provides leadership, coaching, and clinical oversight to UM staff including nurses and support personnel, ensuring compliance with regulatory requirements, accreditation standards, and organizational policies.

Essential Functions/Key Responsibilities:

• Supervise daily activities of the UM team, including nurses and administrative support staff.
• Ensure timely and accurate medical necessity reviews for inpatient, outpatient, and other healthcare services according to internal protocols and regulatory guidelines.
• Monitor workloads, productivity, and performance metrics to ensure team efficiency and effectiveness.
• Provide clinical oversight and guidance on complex cases and escalate when needed.
• Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer requirements.
• Collaborate with medical directors, providers, and case management staff to coordinate appropriate care and avoid unnecessary utilization.
• Participate in audits, reporting, and performance improvement initiatives.
• Train, mentor, and evaluate staff performance; participate in hiring and disciplinary processes.
• Develop and implement standard operating procedures (SOPs) for UM functions.
• Stay updated on changes in healthcare regulations, utilization trends, and evidence-based clinical guidelines.

Competencies:

• Leads by example, motivates others, and supervisors team dynamics effectively. 
• Thrives in fast paced, evolving environments and adjusts quickly to changing client needs. 
• Applies sound clinical reasoning to support decision making and guidance. 
• Builds trust with clients, anticipates their needs, and delivers high value outcomes. 
• Sets clear expectations, measures performance, and takes ownership of outcomes.
• Works cross functionally with internal teams and client stakeholders to achieve aligned goals. 
• Anticipates challenges, investigates root causes and develops solutions. 
• Provides regular feedback and mentors team.
• Champions operational efficiency. 

Required education and experience:

• Minimum 5 years of Utilization Management experience.
• At least 2 years of leadership or team management in a UM setting.
• Active, unrestricted RN license required
• Strong understanding of InterQual and/or MCG criteria.
• Experience managing remote clinical teams across multiple engagements
• Familiarity with Medicare, Medicaid, and commercial payer UM requirements.
• Excellent communication, data analysis, and problem-solving skills.

Preferred education, certifications and/or experience:

• Bachelor’s degree in Nursing (BSN) 
• Consulting or project-based experience preferred.

Physical Requirements/Work environment:

• Remote role with occasional travel (Less than 5%)
• Must have a home office, mobile phone, computer with security requirements met.
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.