AI-Driven Utilization Management Leader

Socket.dev; La Crosse (WI); On-site; USD 100,000 - 140,000; Full time

Benefits offered by this job

Comprehensive benefits package

Competitive retirement program

Job summary

Emplify Health in La Crosse, WI, seeks a Manager of Utilization Management Services to lead a team of about 20 professionals. You will drive appropriate level-of-care determinations, ensure regulatory compliance, and optimize reimbursement across the organization.

You'll collaborate with physicians and operational leaders to improve workflows and guide the adoption of new technologies, including AI-enabled tools, while fostering accountability and continuous improvement.

Qualifications

• Leadership experience supervising a healthcare team.
• Strong understanding of utilization management processes.
• Experience driving process improvements and change management initiatives.
• Active RN license in the state of practice or RHIT/RHIA credential as applicable.

Responsibilities

• Provide operational and administrative leadership for Utilization Management Services.
• Lead and develop a department of approximately 20 team members.
• Oversee utilization review operations, medical necessity determinations, denials management, and appeals processes.
• Partner with physicians, medical directors, clinicians, and leaders to drive utilization management practices.
• Ensure regulatory, payer, and organizational compliance.
• Monitor department performance and align fiscal responsibility with reimbursement goals.
• Lead workflow improvement initiatives and support the adoption of new technologies including AI-enabled tools.
• Foster accountability, collaboration, and continuous improvement.

Skills

Leadership experience

Healthcare collaboration

Regulatory & compliance awareness

Change management mindset

Education

Associate degree in Nursing or Health Information Management with RHIT certification

Bachelor's degree in Nursing or Health Information Management with RHIA certification

Job description

Emplify Health in La Crosse, WI, seeks a Manager of Utilization Management Services to lead a team of about 20 professionals. You will drive appropriate level-of-care determinations, ensure regulatory compliance, and optimize reimbursement across the organization.

You'll collaborate with physicians and operational leaders to improve workflows and guide the adoption of new technologies, including AI-enabled tools, while fostering accountability and continuous improvement.