Director of Utilization Management

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  • 20-00008
  • Direct Placement
  • Managed Care Nursing
  • Alhambra, CA
Job Description
Job Title
Director of Utilization Management; RN
(IPA/Health Plan)
Alhambra, CA 

Great opportunity for an experienced Director of Utilization Management candidate to Direct the UM/Care Management efforts of a dedicated health services organization.
Primary duties and responsibilities:

  • Directs and manages all aspects of Utilization and Care Management Department operations
  • Oversight of department compliance with regulatory requirements of local, state, federal, and private agencies
  • Establishes, maintains, and achieves department goals that are aligned with  initiatives, including but not limited to established turn-around time requirements
  • Oversees and directs department staff to ensure established performance standards are met
  • Following established guidelines, prospectively and retrospectively evaluates the medical necessity, appropriateness, and efficiency of medical services and procedures provided to  members (Commercial, MA, and Duals)
  • Coordinates cost effective care supported by clinical practice guidelines
  • Accurately and comprehensively ensures that all Utilization and Care Management decisions are based on standards of practice and established guidelines, and in compliance with  policies and procedures
  • Works with the clinical services department staff to develop and manage annual Utilization and Care Management Work Plans
  • Acts as a resource for  and  staff regarding issues relating to the Utilization and Care Management Department
  • Interacts and communicates with multidisciplinary teams to ensure continuity and coordination of Members' care
  • Works with physician reviewers and committees to ensure high quality, cost effective care for  Members

Position Requirements

  • Current, unrestricted California RN license
  • B.S.N. Degree strongly preferred
  • Minimum five (5) years management level experience
  • Health plan and/or delegated medical group utilization management experience
  • Thorough knowledge and understanding of health plan utilization and care management operations, including guidelines, workflows, regulations, etc.
  • Thorough knowledge and understanding of insurance and health plan concepts and operations
  • The ability to establish and maintain professional relationships and effective communication with a wide variety of people and to work as a leader and team member
  • Strong multi-tasking skills with the ability to set appropriate priorities
  • Effective leadership and management skills
  • Ability to perform in a fast-paced working environment
  • Demonstrated high degree of personal integrity, precision, and attention to detail
  • Excellent delegation and communication skills


  • Commensurate with Experience

Additional Information

  • Full Time, M-F
  • Direct Placement; Benefited; Exempt  



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