Manager, Clinical Utilization Management

Job Description

Job Description

The Manager, Utilization Management (UM) is responsible for providing strategic leadership and operational oversight for both inpatient and outpatient utilization management clinical teams, including prior authorization, concurrent review, and care coordination functions. This role is accountable for driving clinical quality outcomes, reducing medical loss ratio (MLR), decreasing avoidable admissions and readmissions, and aligning utilization management activities with organizational quality metrics and regulatory requirements.

The Manager ensures appropriate utilization of healthcare services across the continuum of care, with a strong focus on proactive discharge planning, high risk population management, and interdisciplinary collaboration. This position partners closely with Case Management, High Risk Care Management, Pharmacy, Medical Directors, and Clinical Operations to develop clinical solutions that optimize patient outcomes while maintaining cost effective care delivery.

This role also participates in a rotational management on call program, providing leadership support during after hours and weekend periods as needed.

Essential Position Functions/Responsibilities:

• Provide strategic and operational leadership for inpatient and outpatient utilization management teams
• Oversee Prior Authorization, Concurrent Review, and Inpatient Utilization functions
• Manage clinical staff across UM teams
• Establish departmental goals aligned with organizational strategic objectives
• Promote a culture of accountability, collaboration, and continuous improvement
• Ensure staff adherence to policies, procedures, and regulatory requirements
• Conduct performance evaluations, coaching, and professional development planning
• Maintain appropriate staffing models to support operational efficiency and service levels
• Monitor and analyze utilization data to identify trends, opportunities, and performance gaps
• Drive initiatives to reduce admissions, readmissions, and unnecessary utilization
• Implement strategies to reduce medical loss ratio (MLR) while maintaining quality outcomes
• Ensure alignment with clinical quality metrics and population health initiatives
• Oversee appropriate application of clinical criteria including MCG and payer guidelines
• Audit utilization decisions for clinical appropriateness and compliance
• Evaluate and improve workflows to enhance operational efficiency
• Monitor turnaround time, productivity, and key performance indicators
• Lead development and monitoring of utilization management programs
• Partner with Director of Pharmacy to develop clinical solutions and optimize medication utilization
• Collaborate with High Risk Care Management team to address complex populations
• Work closely with Medical Directors to support clinical decision making
• Coordinate and develop with Case Management leadership and Social Work Team alignment of organizational and departmental goals that full align with the SVP of Clinical Services
• Collaborate with Quality, Pharmacy, and Appeals teams
• Participate in Utilization Management Committee
• Ensure compliance with CMS, NCQA, State, Federal, and Department of Labor requirements
• Maintain regulatory readiness and audit preparedness
• Lead internal audits and quality improvement initiatives
• Develop and maintain policies, procedures, and standard operating procedures
• Participate in external and internal audits as subject matter expert
• Develop and monitor departmental KPIs
• Prepare weekly and monthly utilization reports
• Analyze utilization trends and financial impact
• Provide leadership reporting and recommendations
• Monitor turnaround times and productivity metrics
• Provide day to day operational oversight for inpatient and outpatient teams
• Monitor staffing productivity and workflow efficiency
• Implement process improvements and operational initiatives
• Support implementation of new programs and technologies
• Participate in strategic planning initiatives
• Participate in rotational management on call schedule
• Provide leadership coverage during evenings, weekends, and holidays
• Support escalation management and operational decision making

Qualification Requirements:
Skills, Knowledge, Abilities

• Strong knowledge of Utilization Management principles
• Knowledge of MCG, CMS, NCQA, and regulatory requirements
• Understanding of Medicare, Medicaid, and Commercial payer guidelines
• Experience with care coordination and transitions of care
• Strong analytical and problem solving skills
• Excellent communication and leadership skills
• Ability to manage multiple priorities in a fast paced environment
• Strong organizational and time management skills
• Ability to lead change and drive performance improvement
• Experience with quality improvement initiatives
• Ability to build collaborative relationships across departments

Training/Education:

• Bachelor of Science in Nursing (BSN) required
• Master's degree in Nursing, Healthcare Administration, or related field preferred
• Active, unrestricted Registered Nurse (RN) license required

Experience:

• Minimum five (5) years of clinical experience required
• Minimum three (3) years of leadership or supervisory experience required
• Utilization Management experience in Managed Care required
• Inpatient Utilization Management experience preferred
• Prior Authorization experience preferred
• Experience managing interdisciplinary teams preferred