Responsibilities
Ready To
What You'll Actually Do
ESSENTIAL DUTIES and RESPONSIBILITIES:
Level I
· Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows.
· Provide full people management for assigned Utilization Management teams, including hiring, performance management, and staff development.
· Provide routine coaching, feedback, auditing, support and disciplinary action to ensure productivity, quality, and timeliness standards are met.
· Participate in hiring, onboarding, and training of Utilization Management staff.
· Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements.
· Escalate clinical, operational, and performance issues appropriately to leadership.
· Reinforce policies, procedures, and clinical guidelines through regular communication and staff education.
· Support audit readiness by ensuring staff compliance with documentation and timeliness standards.
· Maintain HIPAA compliance, confidentiality, and minimum necessary access at all times.
· Solid knowledge and understanding of medical necessity criteria across inpatient, outpatient, concurrent, and retrospective reviews, with the ability to coach staff on clinical rationale, documentation quality and timeliness.
Level II
· Same as above
· Drive team performance against key metrics, including engagement, productivity, quality scores, and turnaround times.
· Analyze operational and quality data to identify trends, gaps, and opportunities for improvement.
· Lead documentation audits and implement corrective actions to ensure regulatory and accreditation compliance.
· Collaborate with cross-functional partners (CM, CDM, Appeals, Provider Relations, Quality, and Operations) to resolve issues and improve care coordination.
· Support implementation of workflow changes, new programs, or system enhancements.
· Ensure consistent application of policies, clinical criteria, and plan language across the team.
· Prepare team for internal and external audits (e.g., NCQA, URAC) and support responses to findings.
· Serve as a subject matter resource for staff and peers related to Case Management operations and standards.
· Demonstrated ability to work independently with excellent judgment and consistent application of regulatory requirements.
· Utilizes analytical and problem-solving skills to identify and review pertinent information and create action plans
· Serves as an interdepartmental company and external group resource
· Identifies gaps in process and policies compliance issues and implements solutions
· Acts as a Change Champion
Senior
· Same as Level I and Level II
· Provides strategic leadership and oversight for UM operations across multiple teams or functions.
· Serves as a senior subject matter expert in utilization review, regulatory compliance, and clinical operations.
· Leads complex initiatives involving process redesign, system optimization, and performance improvement.
· Partners with executive and cross-functional leaders to align UM strategy with organizational goals.
· Oversees achievement of performance guarantees, audit readiness, and sustained regulatory compliance.
· Interprets and applies advanced regulatory, legal, and accreditation requirements, providing guidance to leadership and staff.
· Mentors and develops managers, supporting leadership growth and succession planning.
· Analyzes enterprise-level performance metrics and trends to drive data-informed decision-making.
· Leads change management efforts and promotes adoption of best practices and innovation.
· Represents the organization in external audits, regulatory discussions, and stakeholder engagements as needed.
· Compliance and efficiency expert in URAC, NCQA, ERISA, and legal requirements
KEY COMPETENCIES:
To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions
UPON HIRE, must have:
· Basic computer literacy
· The ability to work on multiple screens, and proficient typing skills.
· Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
· Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
· Ability to work independently and utilize written resources to problem solve.
· Ability to work independently within appropriate programs after training.
· Knowledge of medical claims and ICD-10, CPT, HCPCS coding
· Excellent verbal and written communication skills for upward and downward conversations
Qualifications
What You Bring to Our Team
Level I
• Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable).
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
• 1-2 years in care management, utilization management, discharge planning, or related clinical coordination
• Minimum 1 year of compliance related experience preferred.
• Certification in Case Management or Utilization Review preferred but not required.
• 1+ year of informal leadership (preceptor/mentor/lead) or some direct people leadership
• Working understanding of HIPAA, member rights, scope of practice, and documentation requirements
• Comfort following policies and escalating risk/safety concerns appropriately
• Coaching fundamentals (1:1s, feedback, basic performance support)
• Strong written communication (member notes, provider communications)
• Basic data literacy: productivity, caseload management, simple reports/dashboards
• Conflict de-escalation and customer service mindset (members/providers)
Level II
• Certification in relevant field preferred
• 3+ years in care management or closely related clinical operations
• 3+ years managing a Utilization Management team (or multiple pods/teams)
• Evidence of initiating and leading process improvement and implementations
• Critical Thinking with the understanding of efficient workflows
• Ownership of KPIs: engagement, outreach effectiveness, transitions of care, closure rates, care gap support
• Staffing and workflow optimization (queue management, triage rules, prioritization)
• Ability to standardize documentation, audit quality, and reduce variation
• Practical understanding of audit readiness (internal audits, corrective action plans)
• Experience interpreting and operationalizing policies, UM/CM timeliness expectations, and documentation standards as it relates to accreditation.
• Ability to lead through change and reinforce consistent practice models
• Works effectively with UM, provider relations, claims, appeals/grievances, pharmacy, behavioral health, and vendor partners
• Strong provider communication skills and escalation management
• Master’s Degree strongly preferred
• 5 years progressive experience in CM/health plan clinical operations, population health, or complex care
• 5+ years people leadership, including managers/supervisors or multi-site leadership
• Owns program design and execution: Platform design and implementation.
• Drives measurable outcomes: TAT adherence, audit compliance.
• Budget planning, staffing models, productivity forecasting, vendor management
• Ability to build business cases and evaluate ROI of interventions and toolsLeads audit readiness and corrective actions across teams
• Sets policy interpretation, standard operating procedures, and controls to reduce risk
• Presents to senior leadership, creates dashboards/storytelling with data
• Strong negotiation and influence across departments and with providers/vendors
• Leads large transformations (new platforms, workflow redesign, reorganizations, new regulatory requirements)
• Develops leadership bench strength (succession planning, manager development)
UPON HIRE, must have:
• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• Ability to work independently within appropriate programs after training.
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations
Physical and Mental Requirements:
• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.
Benefits
The Highlights:
• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Unlimited PTO—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.
Compensation: This position offers a base salary range of $95,000 - $105,000. depending on location, skills, and experience. You're eligible for our full benefits package starting day one.
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