Supervisor, Utilization Management (Hybrid Remote, Must have California LVN / RN License)

The Supervisor, Utilization Management (UM), reports to the Manager of UM and oversees the UM department, leading a clinical team and ensuring compliance with CMS regulations. Responsibilities Manage day‑to‑day operations of the UM department, including pre‑service and claims reviews. Supervise licensed and coordinator staff, ensuring adherence to CMS and Alignment Health turnaround times. Promote quality patient care outcomes while supporting appropriate resource management. Audit and complete reports to meet CMS compliance requirements. Implement and maintain UM processes, including medical claims review and program policies. Collaborate with primary care physicians, specialty providers, mental health professionals, home health professionals, and other stakeholders. Coordinate care internally and externally to put the member first and manage benefits appropriately. Participate in vendor meetings and internal policy reviews. Handle escalated UM cases as required. Supervisory Responsibility Recruit, select, orient, and train UM clinicians and coordinators. Assign workloads, monitor performance and conduct performance appraisals. Conduct 1:1 coaching, disciplinary actions, and corrective action plans. Manage time‑off requests, scheduling, and overtime utilization. Foster an environment that encourages growth and engagement of team members. Job Requirements Experience: Minimum 1 year of recent supervisory experience in utilization management; minimum 2 years of related managed care experience (inpatient and pre‑service UM). Education: Successful completion of an accredited Registered Nursing Program or Vocational Nursing program. Licensure: Active, valid, and unrestricted RN or LVN license in California (non‑compact). Upon hire, must obtain LVN and/or RN licenses in Nevada, Arizona, North Carolina, and Texas, reimbursed by company. Preferred Certifications: CCM or ABQAURP. Specialized Skills: Knowledge of Medicare Managed Care Manuals, CMS regulatory requirements; proficiency with clinical criteria (MCG, InterQual, Apollo, CMS National & Local Coverage Determinations). Computer Skills: Word, Excel, Outlook. Communication: Effective written and oral communication; ability to build constructive relationships with staff, vendors, and providers. Analytical Skills: Ability to interpret and analyze statistical reports; perform basic mathematical calculations. Reasoning & Problem‑Solving: Prioritize multiple tasks, advanced problem‑solving, and design appropriate resolutions. Pay Range $85,696.00 – $128,543.00 (may vary based on location, education, responsibilities, and experience). Equal Opportunity Statement Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. #J-18808-Ljbffr E2E Alignment Healthcare USA, LLC