Manager Utilization Management

Job Summary

The Manager of Utilization Management leads medical necessity review functions, including precertifications, concurrent reviews, alternative care setting authorizations, and pre-service requests. This role ensures evidence-based, compliant care across all lines of business while partnering with internal teams, providers, and vendors to optimize outcomes, drive quality improvement, and maintain regulatory accreditation standards.

What you'll do

• Lead Utilization Management operations for pre-service requests, predeterminations, and concurrent reviews, ensuring adherence to all regulatory and accreditation requirements.
• Maintain current knowledge on industry trends, clinical research, standards of care, and evidence-based guidelines to guide appropriate care and comprehensive Utilization Management practices.
• Support and advance quality management initiatives that measure, monitor, and improve quality-based activities and outcomes, including programs such as HEDIS, QRS, QIS, and Stars.
• Drive accountability and performance excellence across teams through objective performance management and regular Inter-Rater Reliability testing to ensure consistent Utilization Management decision-making.
• Serve as a Subject Matter Expert for URAC Health Utilization Management Accreditation, FEP UM activities, Mental Health Parity, as well as ensuring all jobs functions are performed within the scope of the Kansas Nurse Practice Act.
• Manage departmental budgets responsibly, ensuring proactive and intentional financial stewardship across all teams.
• Act as the primary liaison for Blue Card care management activities, collaborating with provider relations, sales, and other internal partners to resolve provider issues and support special business arrangements.
• Oversee vendor relationships through effective delegated oversight, ensuring UM activities meet accreditation standards and comply with state and federal regulations, including CMS and Medicare Advantage requirements.
• Use data insights to guide operational improvements, accelerate divisional goals, and foster a positive, high-performance culture that inspires exceptional work.
• Lead and develop UM staff, fostering a culture of accountability and continuous improvement.
• Assign work, evaluate performance, and support workflow optimization.

What you need

• Awareness and understanding of medical necessity, utilization patterns, standards of practice, and health care environment as they relate to all programs and staffing.
• Demonstrated ability to communicate effectively across multiple channels while maintaining professionalism and confidentiality.
• Effective time management, independent decision-making, and prioritization skills with flexibility to respond to changing priorities.
• Ability to obtain and analyze utilization, system, and workflow data.
• Credentials required: Bachelor's degree in healthcare administration, public health, or a related field; or equivalent combination of education and experience.
• Experience: Minimum of 5 years of relevant experience in healthcare administration, utilization management, or a related field.
• Skills: Strong analytical, problem-solving, and interpersonal skills; proficiency in Microsoft Office Suite; knowledge of healthcare regulations and standards.

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package.
• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources