Nurse Case Manager - CFHP (PLEASANTON)

POSITION SUMMARY/RESPONSIBILITIES

Provides strategic leadership for Utilization Management programs and initiatives. Responsible for accreditation readiness, regulatory compliance oversight, performance improvement planning, delegated oversight, operational governance, and implementation of organizational UM strategies. Serves as a liaison between operational leadership, Medical Directors, executive leadership, regulatory agencies, and accreditation organizations.

Provides leadership, oversight, direction, and performance management for Utilization Management staff, including clinical reviewers, denial and appeals staff, and administrative personnel. Oversees utilization review operations, prior authorization activities, concurrent review, retrospective review, appeals support, and regulatory compliance activities. Ensures consistent application of medical necessity criteria, regulatory requirements, accreditation standards, and organizational policies. Leads quality improvement initiatives, audit readiness activities, inter-rater reliability processes, staff development, and operational performance monitoring. Collaborates with Medical Directors, Care Management, Provider Relations, Compliance, Quality Management, and other departments to ensure appropriate utilization of healthcare resources, timely determinations, regulatory compliance, and member-centered care.

EDUCATION/EXPERIENCE

Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN). A Master's degree is preferred.

Minimum five (5) years of Utilization Management experience and two (2) years of management or leadership experience are required.

Demonstrated knowledge of:

• NCQA Utilization Management Standards
• URAC Utilization Management Standards
• CMS Managed Care requirements
• Texas Medicaid Managed Care regulations
• Medical necessity review criteria, including InterQual®, MCG®, and/or organization-approved clinical review criteria
• Utilization Management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management
• Regulatory compliance, accreditation readiness, quality improvement, and performance monitoring

Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required . A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), Utilization Management Certification, or other related certification is required. If certification is not held at the time of hire, certification may be required within two (2) years of hire or transfer into the position, consistent with organizational requirements.