Utilization Management Director (RN)

OUR COMMITMENT TO A HUMAN HIRING PROCESS

We believe every candidate deserves thoughtful wedo not use AI or automated systems toreview applications. Every application is reviewed bya realhumanmember of our team. Because we take the time to give each submission the attention it deserves our review process may take a little longer and we genuinely appreciate your patience as we work through applications carefully and respectfully.

SERVICE AREA PREFERENCE

While we encourage all interested applicants to apply we do give priority to those who live in or near our service counties: Santa Cruz Monterey Merced San Benito and Mariposa. Our mission ofaccessible quality health care guided by local innovationleadseverything we do and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.

We have an opportunity to join the Alliance as the Utilization Management Director (RN) leading the Utilization Management Department. *This is a hybrid position with the expectation to work in our service area(s) approximately 1-2 days per month.

WHAT YOULL BE RESPONSIBLE FOR

Reporting to the Health Services Executive Director this position:

• Leads and shapes the Utilization Management (UM) Strategy for the Alliance while providing management oversight in implementing directing and monitoring the Utilization Management Department functions including prior authorizations concurrent review medical claims review appeals and grievance
• Directs the Utilization Management Department acts as a subject matter expert and provides direction and advice on the Departments functions and overall business operations
• Directs manages and supervises Utilization Management Department staff

ABOUT US

Our mission is to optimize members healthcare outcomes through evidenced-based clinical management stewardship and collaboration with provider and community partners.

THE IDEAL CANDIDATE

• A strong clinical leader with deep UM expertise who brings sound judgment regulatory awareness and a commitment to missiondriven decisionmaking.
• Relationshipcentered and impactminded able to balance oversight of the Utilization Management department with a collaborative approach that maintains trust across internal teams and external partners.
• Strategic changeready and operationally adept guiding teams through evolving priorities articulating organizational shifts with clarity and advancing process improvements and crossfunctional projects that strengthen UM operations.
• A transparent communicator and mentor skilled at prioritizing supporting team growth modeling accountability and sustaining momentum while adapting thoughtfully as work evolves.
• A bridgebuilder who sees the big picture collaborating across functions presenting confidently and fostering alignment and cohesion in a fastmoving environment.

WHAT YOULL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements click here.

• Knowledge of:
• The principles and practices of utilization management
• The principles and practices of clinical nursing
• Title 22 Knox Keene Medicaid Medicare entitlement programs and related regulations
• The principles and practices of managed care
• UM documentation requirements necessary to satisfy regulatory audits
• Ability to:
  • Direct manage supervise mentor train and evaluate the work of staff
  • Provide leadership facilitate meetings and partner with and guide managers and employees in the resolution of issues
  • Develop plan organize and direct programs and activities that are complex in nature and regional in scope
  • To identify evaluate and implement innovations and solutions to optimize enhance and expand UM programs and activities
  • Demonstrate a collaborative management style build rapport and effectively manage internal and external business relationships including with members of the medical community community agencies and board members
• Education and Experience:
  • Current unrestricted license as a Registered Nurse issued by the state of California
  • Bachelors degree in Nursing
  • A minimum of ten years of utilization management experience which included a minimum of five years of experience in a managed care environment and three years of staff management experience (a Masters degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

COMPENSATION INFORMATION

• Zone 1 Pay Range: $213K- $245K
  Typical areas in Zone 1: Santa Cruz San Benito and Monterey Counties Bay Area Sacramento Los Angeles and San Diego areas

• Zone 2 Pay Range: $200K - $230K
  Typical areas in Zone 2: Mariposa and Merced Counties Fresno area Bakersfield Eastern California San Luis Obispo area and the Central Valley (except Sacramento)

The applicable salary ranges are based on work location and are aligned to a zone according to the cost of labor in your area. All ranges are subject to change in the future. We are happy toprovidethe full compensation range for the role answer any questions that you have or share the applicable pay zone for your location ifitsnot one of the typical areas listed. You can reach out to and a member from our Talent Acquisition team will be in touch.

The hiring rangesrepresenta goodfaith estimate of what we expect to pay for this role upon hire and are not the full compensation ranges. Employees typically have opportunities for growth within the full compensation range over time based on performance and merit. Final compensation will bedeterminedby our compensation philosophy analysis of the selected candidates qualifications (direct or transferable experience related to the position education or training) as well as other factors (internal equity market factors and geographic location).

OUR BENEFITS

• Medical Dental and Vision Plans
• Ample Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• Robust Health and Wellness Program
• Onsite EV Charging Stations
• And many more

ABOUT US

We are a group of over 500 dedicated employees committed to our mission of providing accessible quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race color religion sex (including pregnancy) sexual orientation gender perception or identity national origin age marital status protected veteran status or disability status. We are an E-Verify participating employer

Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children adults seniors and people with disabilities in Mariposa Merced San Benito and Santa Cruz counties. We currently serve more than 418000 members. To learn more about us take a look at ourFact Sheet.

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time ongoing basis without current or future needs for any type of employer supported or provided sponsorship.