Lead utilization management and care management functions for a health plan, overseeing clinical review processes that support appropriate, efficient, and high-quality coverage decisions for members. The role centers on prior authorizations, concurrent review, appeals, grievances, and medical claims review, with a strong emphasis on regulatory compliance and accreditation standards. It also involves workflow redesign, data-driven process improvement, and collaboration with internal teams, providers, and vendors to improve care quality and administrative efficiency.
Key Responsibilities
- Develop and implement utilization management and care management strategies using data analytics, technology, and cost-benefit analysis.
- Participate in creating, revising, and enforcing UM/CM policies, procedures, and protocols to meet regulatory and accreditation requirements.
- Manage provider reviewers, concurrent review, prior authorization, medical claims review, appeals, and grievances from a clinical perspective.
- Identify workflow improvements and support automation efforts such as auto-approvals, alternative site criteria evaluation, and AI-enabled solutions.
- Participate in value-based care and system innovation efforts that reduce administrative burden and improve member and provider experience.
- Monitor utilization trends, productivity metrics, cost savings, and quality outcomes across areas of responsibility.
- Build relationships with vendors and clinical teams to improve care quality and operational efficiency.
- Provide provider education, supervision, and mentorship to UM/CM staff while supporting compliance and workforce planning.
Required
- MD or DO degree.
- Board certification in Internal Medicine, Pediatrics, Family Practice, Psychiatry, or Emergency Medicine.
- Current licensure in Utah, Idaho, Nevada, or Colorado.
- At least 5 years of clinical practice experience.
Preferred
- Experience in utilization management or care management.
- Experience with policy-related work for a health plan or managed care organization.
- Previous management experience.
- Experience with financial and medical expense management.
- Understanding of government programs and agencies within the health care delivery system.
Benefits & Perks
- Annual leadership incentive opportunity based on system goals.
- Sign-on bonus may be offered when applicable.
- Relocation bonus may be offered when applicable.
- Comprehensive benefits package focused on wellness and caregiver support.
- Scheduled weekly hours: 36.