Manager of Utilization Management and Complex Care Management

About the Role

The Manager of Utilization Management and Complex Care Management provides day-to-day operational leadership for the Utilization Management, Transitional Care, and Care Management teams. This role supports the execution of processes designed to improve health outcomes, reduce healthcare utilization costs, and facilitate effective care transitions for complex populations. The Manager collaborates closely with Medical Center leadership, Market Leadership, and other stakeholders to ensure a seamless continuum of care across inpatient, ambulatory, and community-based settings. Success in this role is measured by meeting and/or exceeding KPI targets around Admissions/1000, Readmissions/1000, Average length of stay, and ED Utilization.

Responsibilities

• Lead and manage a diverse care management team, including registered nurses, social workers, and community health workers.
• Oversee staff development and ensure adherence to care management standards, including person-centered care planning, SMART goals, and documentation protocols aligned with NCQA, regulatory, and health plan standards.
• Conduct performance management activities, including case audits, one-on-one coaching, and training, ensuring compliance with quality and accreditation standards.
• Manage caseloads to ensure follow-up, timely documentation, and compliance with organizational and health plan requirements.
• Coordinate with community-based organizations, primary care providers, and specialists to address members’ chronic care needs, facilitate transitions of care, and support member retention.
• Partner with inpatient facility case management departments for collaborative discharge planning and continuity of care.
• Host and document interdisciplinary care team (ICT) meetings, ensuring follow-up on action items to enhance member outcomes.
• Use data and reporting to monitor team performance and drive improvements in utilization, health outcomes, quality metrics, and member satisfaction.
• Proactively identify low-performing staff or processes, implementing improvement plans or process optimizations as needed.
• Apply evidence-based guidelines (e.g., MCG, InterQual) to ensure appropriate levels of care, reduce readmissions, and improve transitions.
• Serve as a subject matter expert (SME) on care management, chronic conditions, and organizational information systems, leading training and promoting best practices in member care.
• Address complex needs of populations with medical, behavioral, and socioeconomic barriers through data-driven interventions and therapeutic approaches such as motivational interviewing and trauma-informed care.
• Develop and maintain relationships with payors, facility leadership, and community organizations to support integrated member care and overcome barriers such as housing, food security, and financial instability.
• Actively participate in both internal and external meetings, representing the organization’s mission, vision, and values.
• Conduct interviews, hiring, onboarding, and training for new team members, ensuring alignment with organizational goals.
• Lead team meetings, engage in team-building activities, and maintain staff morale and productivity through virtual and in-person methods.
• Maintain the privacy and security of member information as per organizational and legal standards.
• Adapt to dynamic environments, managing competing priorities and supporting business needs through flexible, innovative solutions.
• Meet deadlines and uphold organizational core values in daily operations.

Requirements

• Current, active, and unrestricted license in a health or human services discipline that allows you to conduct an assessment independently (e.g., RN, SW).
• Qualified with CCM Credentials or obtain within 24 months of hire. CMGT-BC, CCTM, C-SWCM, C-ASWCM, ACM, or FAACM will be considered.
• BLS/CPR required.
• Bachelor’s degree in health or human services discipline required.
• Master’s degree in business, Healthcare Administration/Public Health, Finance, or a related field a plus.
• Advanced clinical practice (e.g., CNS/APN, LCSW/LISW, PsyD/PhD) a plus.
• Other certifications considered: CMAC, CHE, CPHQ or similar certifications a plus.

Experience

• 7-10 years’ experience, with at least 3-5 years in leadership, ideally in Value-Based Care, Utilization Management, or Complex Care Management.
• Experience with complex populations (e.g., Medicaid, Medicare, dual-eligibles), including medically complex, trauma-experienced, and socially vulnerable individuals.
• Proficiency with evidence-based care transition strategies, including discharge planning, ambulatory care, and community-based care coordination.

Skills

• Advanced computer skills in Microsoft Office Suite and electronic health record (EHR) systems.
• Strong data analysis and reporting abilities to drive performance improvements and process optimization.
• Excellent verbal and written communication skills for interactions with members, families, stakeholders, and interdisciplinary teams.
• Proven ability to foster team morale, handle change, and work independently while making sound clinical judgments.

Working Conditions

• Frequent communication with team members, partners, and patients, requiring clarity and accuracy.
• Ability to work both in community settings and in a professional office environment.
• Ability to operate electronic portable devices and complete documentation and other tasks in a mobile work environment.
• Ability to travel regionally and nationally up to 80%.
• Ability to occasionally move objects up to 20 lbs.
• Valid driver’s license with automobile insurance, with ability to travel up to 80% within the local area.
• Reliable transportation.
• This role is expected to travel between the center as well as local facilities (e.g., hospitals, SNFs).

Direct Reports

May include any combination of:

• Transitional Care Managers
• Complex Care Managers
• Team Lead (if present)