Utilization Management Manager (CA Licensed)

About the Role

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Responsibilities

• Design utilization management programs, processes, and workflows to meet operational goals and anticipate future strategic needs.
• Evaluate ability to automate and streamline standard work.
• Analyze and monitor quality, cost reimbursement, and utilization trends.
• Support system migration planning, preparation, and execution to ensure a seamless operational transition.
• Develop and oversee inpatient and outpatient utilization management programs to ensure:
  • Cost-effective use of patient care resources.
  • Case delivery at the most appropriate level.
  • Collaboration with the medical staff on resource utilization issues.
  • Compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates.
• Provide support for health plan market/product-level operational oversight, management, and performance improvement.
• Leverage industry expertise and knowledge to provide high-value consulting and advisory services.
• Deliver integrated solutions in support of client goals and engagements.
• Provide delivery assurance support for engagements with assigned clients.
• Support engagements ensuring completion of contracted services.
• Create and/or manage project plans.
• Prepare materials for presentation to client executives.
• Facilitate and inform key decisions through the use of data and industry best practice sharing.
• Deliver concise, clear interpersonal communication to both internal and external audiences.
• Facilitate streamlined exchange of information with engagement manager and client organization partner(s).
• Leverage proven methodologies and best practices in support of individual account strategies/client plans.
• Establish goals and track progress to ensure achievement.
• Act in an interim leadership capacity to provide supervision and oversight for teams and activities in a direct supervisory model.
• Identify opportunities to improve workflow, generate accurate, high-quality productivity, support organizational compliance with requirements, and deliver reductions in associated costs with improvement in organizational quality performance in collaboration with client leaders.
• Develop or update policies and procedures as required to support business needs and requirements.
• Identify opportunities to streamline and/or automate workflows.
• Manage and develop staff to reach established engagement goals, deliverables, and KPIs.
• Adapt processes, approach, plan, and/or activities in real time to ensure critical path activities are achieved.
• Support account management relationships with key client decision-makers.
• Develop and deploy management reporting, if indicated, to support monitoring and improvement of performance, implementing plans for improvement as necessary.
• Ensure quality, maintain appropriate resources, competency training, and education of staff.
• Approve and manage day-to-day engagement resourcing/time and attendance as an Engagement Manager.
• Oversee compliance with internal client-related audits, support client preparation for external audits and surveys.

Requirements

• Registered Nurse with current unencumbered California license.
• 3+ years of California Managed Medicaid experience.
• Experience in Quality Assurance (QA) and performance improvement initiatives, with a focus on continuous process optimization and outcomes improvement.
• 2+ years progressive experience in managed care at the Manager level or equivalent, specifically in utilization management, preferably in a government payor environment.
• Bachelor’s Degree preferred; will accept equivalent experience in a managed care environment.
• Experience managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on-time, in-scope project and/or strategic delivery.
• Managed care industry knowledge in operations, costs, requirements, performance, and outcomes.
• Demonstrated ability to work across and apply best practices to multiple Lines of Business (LOBs); Covered California experience strongly preferred.
• Hands-on leader with an owner/operator mindset who actively supports the team and is willing to step into the queue as needed to ensure operational success.
• Strong knowledge of NCQA standards, with the ability to translate requirements into streamlined workflows, operational efficiencies, and process improvements.
• Proven ability to identify operational challenges, develop effective solutions, and drive resolution in a fast-paced environment.
• Product/market operational experience in Commercial, Medicare, Medicare Advantage, Medicaid, or associated lines of business.
• Understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures.
• Understanding of key regulations, frameworks, accreditation, and oversight bodies to ensure compliance with complex regulatory structures.
• Knowledge of project management principles, methods, and techniques.
• Ability to organize and manage multiple competing priorities.
• Strong communication skills, both written and oral.
• High proficiency with core office software (Excel, Word, and PowerPoint); Visio skills preferred.

Physical Requirements

• Must be able to sit in a chair for extended periods of time.
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word.
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices.
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse.
• Must be able to clearly use sight to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types.
• Must be able to fluently communicate both verbally and in writing using the English language.
• Must be able to engage in continuous social interaction, successfully manage stressful high-conflict situations, and balance multiple duties, expectations, and responsibilities simultaneously.

Schedule

Expected hours of work: Monday - Friday, 8 AM – 5 PM PST, with the ability to adjust to client schedules as needed.

Pay

Salary Range: $100,000 - $150,000.