Manager, Medical Utilization and Care Management

Transformcap; United States; On-site; USD 95,000 - 130,000; Full time

Job summary

Transformcap is seeking an RN-licensed leader to oversee vendors delivering utilization management, care management, and clinical operations. You will ensure medical necessity and appropriate care levels while coordinating with medical leadership on complex cases and policy development.

You will supervise prior authorization, peer‑to‑peer reviews, denials and appeals, HRAs, chronic disease programs, and transitions of care, ensuring compliance with URAC/NCQA and payer systems.

Qualifications

• Active unrestricted RN license ( BSN preferred )
• 5+ years of experience in utilization management, care management, or case management
• 2+ years of leadership experience
• Knowledge of medical necessity reviews, care coordination models, and payer systems

Responsibilities

• Provide oversight for vendors conducting utilization management, care management, and clinical operations activities.
• Oversee vendor execution of utilization reviews to ensure medical necessity and appropriate level of care determinations.
• Monitor vendor review of medical records and treatment plans to support appropriate service utilization and optimize reimbursement outcomes.
• Partner with Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations.
• Provide oversight of vendor‑managed prior authorization, peer‑to‑peer review, denial, appeal, and notification processes.
• Ensure vendors complete comprehensive biopsychosocial assessments and HRAs in accordance with program requirements.
• Oversee vendor‑led care coordination across the continuum, including transitions of care and discharge planning.
• Provide oversight of vendor‑administered chronic disease and complex case management programs.
• Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care.
• Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented.
• Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements.
• Coordinate with vendor interdisciplinary teams to promote aligned clinical operations and member outcomes.
• Promote vendor‑delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes.

Skills

Utilization management

Care management

Leadership

Medical necessity reviews

Payer systems

Education

RN license (BSN preferred)

Job description

Position Responsibilities

• Provide oversight for vendors conducting utilization management, care management, and clinical operations activities.
• Oversee vendor execution of utilization reviews, including prospective, concurrent, and retrospective reviews, to ensure medical necessity and appropriate level of care determinations.
• Monitor vendor review of medical records and treatment plans to support appropriate service utilization, avoid unnecessary or duplicate services, and optimize reimbursement outcomes.
• Partner with the Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations.
• Provide oversight of vendor‑managed prior authorization, peer‑to‑peer review, denial, appeal, and notification processes.
• Ensure vendors complete comprehensive biopsychosocial assessments and health risk assessments (HRAs) in accordance with program requirements.
• Oversee vendor‑led care coordination across the continuum, including transitions of care and discharge planning.
• Provide oversight of vendor‑administered chronic disease and complex case management programs.
• Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care.
• Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented.
• Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements.
• Coordinate with vendor interdisciplinary teams, including nurses, social workers, and care coordinators, to promote aligned clinical operations and member outcomes.
• Promote vendor‑delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes.

Required Qualifications

• Active unrestricted RN license (BSN preferred)
• 5+ years of experience in utilization management, care management, or case management
• 2+ years leadership experience
• Knowledge of medical necessity reviews, care coordination models, and payer systems

Preferred Qualifications

• Certification (CCM, CMGT‑BC, HCQM).
• Experience with Commercial, Medicare and Medicaid population.
• Experience working with Medical Directors, Vendors, and Health Systems.
• Knowledge of URAC/NCQA standards.

Salary Ranges

New York, NY: $95,000 — $130,000 USD

Denver, CO: $95,000 — $130,000 USD

Charlotte, NC: $95,000 — $130,000 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non‑compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.