Manager, Clinical Utilization Management

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 teamsOversee Prior Authorization, Concurrent Review, and Inpatient Utilization functionsManage clinical staff across UM teamsEstablish departmental goals aligned with organizational strategic objectivesPromote a culture of accountability, collaboration, and continuous improvementEnsure staff adherence to policies, procedures, and regulatory requirementsConduct performance evaluations, coaching, and professional development planningMaintain appropriate staffing models to support operational efficiency and service levelsMonitor and analyze utilization data to identify trends, opportunities, and performance gapsDrive initiatives to reduce admissions, readmissions, and unnecessary utilizationImplement strategies to reduce medical loss ratio (MLR) while maintaining quality outcomesEnsure alignment with clinical quality metrics and population health initiativesOversee appropriate application of clinical criteria including MCG and payer guidelinesAudit utilization decisions for clinical appropriateness and complianceEvaluate and improve workflows to enhance operational efficiencyMonitor turnaround time, productivity, and key performance indicatorsLead development and monitoring of utilization management programsPartner with Director of Pharmacy to develop clinical solutions and optimize medication utilizationCollaborate with High Risk Care Management team to address complex populationsWork closely with Medical Directors to support clinical decision makingCoordinate and develop with Case Management leadership and Social Work Team alignment of organizational and departmental goals that full align with the SVP of Clinical ServicesCollaborate with Quality, Pharmacy, and Appeals teamsParticipate in Utilization Management CommitteeEnsure compliance with CMS, NCQA, State, Federal, and Department of Labor requirementsMaintain regulatory readiness and audit preparednessLead internal audits and quality improvement initiativesDevelop and maintain policies, procedures, and standard operating proceduresParticipate in external and internal audits as subject matter expertDevelop and monitor departmental KPIsPrepare weekly and monthly utilization reportsAnalyze utilization trends and financial impactProvide leadership reporting and recommendationsMonitor turnaround times and productivity metricsProvide day‐to‐day operational oversight for inpatient and outpatient teamsMonitor staffing productivity and workflow efficiencyImplement process improvements and operational initiativesSupport implementation of new programs and technologiesParticipate in strategic planning initiativesParticipate in rotational management on‐call scheduleProvide leadership coverage during evenings, weekends, and holidaysSupport escalation management and operational decision making Qualification Requirements: Skills, Knowledge, AbilitiesStrong knowledge of Utilization Management principlesKnowledge of MCG, CMS, NCQA, and regulatory requirementsUnderstanding of Medicare, Medicaid, and Commercial payer guidelinesExperience with care coordination and transitions of careStrong analytical and problem‐solving skillsExcellent communication and leadership skillsAbility to manage multiple priorities in a fast‐paced environmentStrong organizational and time management skillsAbility to lead change and drive performance improvementExperience with quality improvement initiativesAbility to build collaborative relationships across departments Training/Education:Bachelor of Science in Nursing (BSN) requiredMaster's degree in Nursing, Healthcare Administration, or related field preferredActive, unrestricted Registered Nurse (RN) license required Experience:Minimum five (5) years of clinical experience requiredMinimum three (3) years of leadership or supervisory experience requiredUtilization Management experience in Managed Care requiredInpatient Utilization Management experience preferredPrior Authorization experience preferredExperience managing interdisciplinary teams preferred