Supervisor, Utilization Management (RN)

Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.

- Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards

- Collaborates with utilization management team to resolve complex care member issues

- Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management

- Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management

- Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers

- Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures

- Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services

- Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones

- Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards

- Assists with onboarding, hiring, and training utilization management team members

- Leads and champions change within scope of responsibility - Performs other duties as assigned

Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience.

- RN - Registered Nurse - State Licensure and/or Compact State Licensure required - CA RN LICENSE REQUIRED