Clinical Utilization & Referral Manager

ADP, Inc.; West Palm Beach (FL); On-site; USD 55,000 - 70,000; Full time

Job summary

ADP, Inc. in West Palm Beach, FL is seeking a experienced Manager, Referral and Patient Care Management to lead our clinical operations in referrals and utilization review.

You will supervise referral coordinators and case managers, ensuring timely, compliant decisions using MCG and other criteria, while collaborating with cross-functional teams to optimize patient care and regulatory compliance.

Qualifications

• Active, unrestricted clinical license required (RN preferred).
• 3–5 years in utilization review, case management, or referral management.
• 1–2 years of supervision / team lead experience.
• Working knowledge of Milliman Care Guidelines (MCG) or equivalent.
• Strong understanding of CMS/NCQA/URAC/state regulatory standards.

Responsibilities

• Lead day-to-day operations of referral processing and case management team.
• Ensure clinically sound medical necessity determinations with proper documentation.
• Oversee performance, coaching, and adherence to SLAs and policies.
• Collaborate with providers and care teams to optimize utilization and transitions of care.
• Support audits and quality reporting related to utilization and case management metrics.

Skills

RN license

Utilization review

Supervisory

MCG knowledge

Regulatory knowledge

Education

Bachelor's degree in Nursing/Health Admin

CCM certification

Tools

Utilization management software

Referral management systems

Job description

ADP, Inc. in West Palm Beach, FL is seeking a experienced Manager, Referral and Patient Care Management to lead our clinical operations in referrals and utilization review.

You will supervise referral coordinators and case managers, ensuring timely, compliant decisions using MCG and other criteria, while collaborating with cross-functional teams to optimize patient care and regulatory compliance.