Director of Utilization Management

Cambia Health Solutions; Burlington (WA); Hybrid; USD 112,000 - 172,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

401(k) with company match

Paid time off

Parental leave

Wellness programs

Job summary

Cambia Health Solutions is seeking a Manager of Utilization Management to lead a team of clinicians and staff across multiple plans. You will oversee prospective, concurrent, retrospective reviews and post-service audits, shape policies, and drive performance against regulatory standards.

The role demands RN licensure, a strong clinical background, leadership experience, and collaboration across departments and stakeholders to improve member outcomes and value.

Qualifications

• Bachelor's degree in nursing or related field, masters preferred
• 5 years of clinical care experience
• 5 years of leadership experience
• 7 years of insurance industry experience or equivalent combination of education and experience
• Current unrestricted Registered Nurse (RN) Licensure, in a state or territory of the United States

Responsibilities

• Leads the development and execution of effective utilization and/or payment review management policies, procedures and standards.
• Handles all management level responsibilities for staff, including performance reviews, employee development, hiring, coaching, counseling, and retention.
• Regularly communicates organizational objectives and team goals. Monitors results and metrics to ensure deliverables are met and compliance with department and regulatory standards.
• Manages financial targets and department budget, authorizes expenditures, monitors workforce allocation and resources, and oversees project plans.
• In conjunction with division leadership, establishes long-term goals for department and adapts operational plans as changes occur.
• Creates visibility and support for utilization management and/or payment review programs. Develops resource materials and provides education and communication about programs to employees, providers and community stakeholders.

Skills

Leadership

Clinical care

Communication

AI tools

Statistical analysis

Education

Bachelor's degree in nursing

Masters preferred

Job description

Cambia Health Solutions is seeking a Manager of Utilization Management to lead a team of clinicians and staff across multiple plans. You will oversee prospective, concurrent, retrospective reviews and post-service audits, shape policies, and drive performance against regulatory standards.

The role demands RN licensure, a strong clinical background, leadership experience, and collaboration across departments and stakeholders to improve member outcomes and value.