Utilization Management Manager

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🕒 vor 10 Tagen

🇺🇸 Vereinigte Staaten – Remote

💵 $115.000 / Jahr

⏰ Vollzeit

🟠 Senior

🔴 Experte

👔 Manager

🦅 H1B-Visum-Sponsor

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Intus Care

WebsiteLinkedInAlle Stellen

11 - 50 Mitarbeiter

💼 Beratung

📣 Marketing

📦 Logistik

💰 €13.100.000 Venture Round im 2023-01

Consulting • Marketing • Logistics

IntusCare ist ein Technologieunternehmen, das sich auf Pflegemanagementlösungen für PACE (Programme der umfassenden Pflege für Ältere) und Medicare-Programme spezialisiert hat. Das Unternehmen bietet verschiedene Werkzeuge und Dienstleistungen an, darunter integrierte Pflegedienste, Risikoadjustierung und Bevölkerungsanalyse, mit dem Ziel, die ergebnisorientierte Versorgung zu verbessern. Mit über 50 Partnerschaften in 18 Bundesstaaten bietet IntusCare innovative Technologien, um komplexe Pflegeprozesse zu optimieren und die Gesundheitsergebnisse zu verbessern, indem klinische Risiken angegangen und eine proaktive Pflegeplanung erleichtert werden.

Beschreibung

• Hold full accountability for UM team performance, including meeting or exceeding all program SLAs (turnaround times, decision timeliness, dispute resolution timelines, documentation completeness, and quality benchmarks). • Establish, monitor, and report on individual and team performance metrics; conduct regular one-on-ones, performance reviews, and coaching sessions to drive accountability and professional growth. • Ensure consistent application of PACE service authorization policies, standard operating procedures, and clinical decision support criteria (e.g., MCG) across every reviewer and every case. • Design and lead ongoing quality assurance (QA) and inter-rater reliability activities; identify variance in decision-making, address it through targeted coaching or process changes, and document outcomes. • Manage staffing, scheduling, workload distribution, and case assignment to ensure sustained SLA performance during volume fluctuations, coverage gaps, and PTO. Perform case reviews as needed during staff PTO to assure timely case completion and accuracy. • Recruit, onboard, and develop UM nurses; build competency-based training programs and structured ramp plans for new hires. • Foster a culture of accountability, collaboration, psychological safety, and continuous improvement. • Maintain and update UM policies, procedures, workflows, and job aids; ensure changes are communicated, trained on, and audited for adoption. • Partner with the contracted IntusCare Contracted Physician to define escalation pathways and ensure clinical decision-making support is available when needed. • Use data analytics to monitor care patterns, cost drivers, length-of-stay trends, denial and overturn rates, and utilization efficiency; translate findings into targeted improvement initiatives. • Lead or sponsor rapid-cycle performance improvement initiatives across UM functions. • Prepare and present program performance reporting to internal leadership and PACE client stakeholders. • Personally handle a defined caseload of UM reviews and provider disputes to remain clinically current, model expected practice, and manage escalations.

🎯 Anforderungen

• Current, active Registered Nurse (RN) license in good standing. • 7+ years of utilization management experience, including experience in risk-based, integrated care models. • 5+ years of direct people-management experience leading a team of clinical reviewers or UM nurses, with clear accountability for team-level SLAs and performance outcomes. • Demonstrated experience owning and improving inter-rater reliability, QA programs, and consistent application of clinical decision support criteria (e.g., MCG, InterQual). • Strong data literacy—able to use dashboards and analytics to diagnose performance gaps and drive targeted interventions. • Proven ability to manage competing priorities in a fast-paced, performance-driven environment. • Excellent written and verbal communication skills, including comfort presenting to executive and client audiences.

🏖️ Vorteile

• Not eligible for sponsorship.