Utilization Management Program Manager
Utilization Management Program Manager
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Job Description
At Collective Health were transforming how employers and their people engage with their health benefits by seamlessly integrating cuttingedge technology compassionate service and worldclass user experience design.
The UM Program Manager will play a critical role in the strategic development effective and efficient delivery and ongoing management of utilization management (UM) programs. The person in this role will own and be accountable to the success of Collective Healths UM programs. To this end the UM program manager will ensure that our processes are proactively aligned with industry best practices regulatory requirements and clientspecific needs; provide clinical oversight manage partner relationships and drive process improvements; and collaborate with internal and external stakeholders to ensure costeffective and medicallyappropriate health care services
What youll do:
Strategic Leadership and Program Development:
- Implement a comprehensive program to manage clinical UM and Prior Authorizations oversight with a focus on scalability and sustainability including establishing policies procedures and workflows that ensure efficient and consistent program execution and align with best practices regulatory requirements (e.g. NCQA URAC) client needs and the TPAs values.
- Plan for future program growth including identifying and recruiting staff with relevant skill sets over a 35 year horizon.
- Define the longterm goals and direction for the UM service line in collaboration with senior leadership.
- Continuously analyze processes and data to find inefficiencies and implement innovative solutions for better outcomes and cost management.
- Contribute to broader organizational goals by developing strategies related to medical management risk adjustment and overall healthcare delivery.
Clinical Expertise and Collaboration:
- Assume clinical ownership of UM and prior authorization services delivered through current and potential vendor partners ensuring adherence to quality standards and contractual obligations.
- Serve as the primary clinical point of contact for UM partners fostering collaborative relationships and driving performance improvements.
- Conduct regular audits of UM performance and participate in case reviews identifying and addressing areas for improvement.
- Serve as an internal subject matter expert on medical necessity criteria evidencebased guidelines and accepted standards of medical practice.
- Maintain a deep understanding of current UM practices regulatory requirements and industry trends.
- Work collaboratively with internal clinical and product teams to provide updates on program performance and ensure seamless program integration and alignment.
- Contribute to the companys fund of knowledge and expertise by educating internal stakeholders on relevant UMrelated topics
To be successful in this role youll need:
- Bachelors degree in Nursing Healthcare Administration or a related clinical field (Masters preferred).
- Active Registered Nurse (RN) license or relevant clinical licensure.
- Minimum of 5 years of direct clinical patient care experience.
- Minimum of 57 years of operational and management experience with utilization management prior authorization or related roles.
- Strong knowledge of UM and prior authorization practices metrics regulatory requirements and industry trends.
- Experience managing vendor relationships including clinical oversight.
- Mastery of coding for prior authorizations
- Strong analytical problemsolving and decisionmaking skills.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively in a fastpaced environment.
- Experience with healthcare technology platforms and data analysis tools.
- Experience working with TPAs or health plans.
Pay Transparency Statement
This is a hybrid position based out of one of our offices: San Francisco CA Plano TX or Lehi UT. Hybrid employees are expected to be in the office three days per week (Plano TX) or two days per week (San Francisco CA and Lehi UT).#LIhybrid
The actual pay rate offered within the range will depend on factors including geographic location qualifications experience and internal equity. In addition to the salary you will be eligible for stock options and benefits like health insurance 401k and paid time off. Learn more about our benefits at Francisco CA Pay Range
Why Join Us
- Missiondriven culture that values innovation collaboration and a commitment to excellence in healthcare
- Impactful projects that shape the future of our organization
- Opportunities for professional development through internal mobility opportunities mentorship programs and courses tailored to your interests
- Flexible work arrangements and a supportive worklife balance
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race religion color national origin gender sexual orientation age marital status veteran status or disability status. Collective Health is committed to providing support to candidates who require reasonable accommodation during the interview process. If you need assistance please contact .
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Manager
Employment Type
Full Time
