RN Case Manager

Director of Utilization Review Orange County, CA

RN - Case Manager (Opportunity for Growth)

A respected behavioral healthcare provider seeks a strategic and experienced Director of Utilization Review to lead and optimize utilization management, social services, and associated administrative teams. This role offers significant opportunity to drive clinical excellence, collaborate regionally, and shape key hospital processes within the behavioral health continuum.

Director of Utilization Review Benefits & Compensation

• Competitive compensation commensurate with experience
• Comprehensive health, dental, and vision coverage
• Generous paid time off and holiday schedule
• Professional development and ongoing training opportunities
• Supportive leadership team and collaborative organizational culture

Director of Utilization Review Requirements & Qualifications

• Current California Registered Nurse (RN) license required
• Minimum five (5) years of progressive leadership in utilization review or management within behavioral health, psychiatric, or acute care settings
• At least three (3) years of direct supervision of utilization review staff
• Strong expertise in behavioral health utilization review, denial management, appeals, length-of-stay, and reimbursement strategies
• Thorough understanding of California behavioral health regulations , Medi-Cal, Medicare, commercial plans, and accreditation standards
• Demonstrated experience with Orange County behavioral health systems, Carelon Behavioral Health, and county-managed mental health services
• Master's degree in Nursing, Healthcare Administration, Social Work, Public Health, or related field preferred

Director of Utilization Review Preferred Background & Skills

• Familiarity with county-funded behavioral health programs and community-based behavioral health services
• Strong analytical, leadership, and performance improvement expertise
• Demonstrated ability to foster collaboration among executive leadership, clinical teams, and external community partners

Director of Utilization Review Day-to-Day Responsibilities

• Provide leadership, oversight, and training for all utilization review, social services, and clerical staff
• Develop, implement, and monitor the hospital's Utilization Management Program, ensuring compliance with all payer, regulatory, and accreditation requirements
• Serve as a key advisor on behavioral health medical necessity criteria, authorization processes, length-of-stay management, and reimbursement optimization
• Oversee denial management activities, including appeals, peer reviews, and reimbursement recovery
• Collect, analyze, and report on utilization data, quality metrics, and financial outcomes, recommending and implementing corrective action plans as needed
• Build and maintain collaborative relationships with county agencies, managed care organizations, and community providers
• Educate and train hospital teams on utilization management, payer expectations, and regulatory changes

This role is ideal for a driven leader eager to advance care standards and operational excellence in the behavioral health field.