Utilization Management Manager

About the role

The Utilization Management (UM) Manager oversees the UM nurse team supporting a Program of All-Inclusive Care for the Elderly (PACE). This role is responsible for delivering high-quality UM services, managing team performance, and driving continuous improvement.

Responsibilities

• Team Leadership & Performance Management: Full accountability for UM team performance, including meeting or exceeding all program SLAs, establishing, monitoring, and reporting on individual and team performance metrics, conducting regular one-on-ones, performance reviews, and coaching sessions.

• Manage Staffing, Scheduling, and Workload Distribution: Ensure sustained SLA performance during volume fluctuations, coverage gaps, and PTO; perform case reviews during staff PTO to assure timely case completion and accuracy; recruit, onboard, and develop UM nurses; build competency-based training programs and structured ramp plans for new hires.

• Recruit, Onboard, and Develop UM Nurses: Foster a culture of accountability, collaboration, psychological safety, and continuous improvement; maintain and update UM policies, procedures, workflows, and job aids; ensure changes are communicated, trained on, and audited for adoption.

• Partner with the Contracted Physician: Define escalation pathways and ensure clinical decision-making support is available when needed; use data analytics to monitor care patterns, cost drivers, length-of-stay trends, denial and overturn rates, and utilization efficiency; translate findings into targeted improvement initiatives.

• Direct UM Case & Dispute Work: Personally handle a defined caseload of UM reviews and provider disputes; collaborate with the PACE program's finance and claims adjudication team to coordinate clinical review supporting disputed claims; collaborate with the IntusCare Contracted Physician to review and respond to disputes, ensuring written determinations consistent with IntusCare policies.

• Stakeholder Engagement & Communication: Partner with PACE organizations, Medical Directors, IDTs, and provider networks to strengthen communication and ensure alignment on authorization decisions and care strategies; facilitate education, training, and cross-functional collaboration to improve UM consistency, documentation accuracy, and compliance with IntusCare standards.

Qualifications

• Current, active Registered Nurse (RN) license in good standing.

• 7+ years of utilization management experience, including experience in risk-based, integrated care models.

• 5+ years of direct people-management experience leading a team of clinical reviewers or UM nurses, with clear accountability for team-level SLAs and performance outcomes.

• Demonstrated experience owning and improving inter-rater reliability, QA programs, and consistent application of clinical decision support criteria (e.g., MCG, InterQual).

• Strong data literacy—able to use dashboards and analytics to diagnose performance gaps and drive targeted interventions.

• Proven ability to manage competing priorities in a fast-paced, performance-driven environment.

• Excellent written and verbal communication skills, including comfort presenting to executive and client audiences.

Preferred Qualifications

• Experience implementing or scaling UM operations across multiple client organizations or sites.

• Certification in case management or utilization review (e.g., CCM, ACM, CPHM).

• Experience with rapid-cycle improvement methodologies (PDSA, Lean, Six Sigma).

Compensation

The base salary for this role is $115,000. Final compensation will be determined based on experience, skills, and organizational needs.