Manager, Utilization Management & Quality Improvement

CareSource; Massachusetts; On-site; USD 83,000 - 133,000; Full time

Benefits offered by this job

Bonus potential

Job summary

CareSource seeks a Manager of Utilization Management to oversee all utilization management activities, ensuring service consistency and meeting utilization targets. The role emphasizes coordination of pre-determination processes, data analysis, and regulatory compliance.

The position requires an RN license, a minimum of five years in clinical roles with UM/CM experience, and strong leadership. Massachusetts location with potential bonus based on performance is noted as part of a comprehensive

Qualifications

• RN licensure in state of practice is required
• Associate's Degree in Nursing required; BSN preferred
• Minimum of five (5) years of clinical experience
• Minimum of five (5) years in case management, utilization management, or quality improvement
• Two years of utilization management experience preferred
• Managed care experience preferred

Responsibilities

• Oversee pre-determination processes for medical and dental services with consistent criteria
• Monitor utilization management data and maintain industry standards
• Collaborate with providers and staff on benefits and regulations
• Review workflows to maximize efficiency and ensure timely decisions
• Report regulatory requirements and maintain trend data
• Audit predetermination requests and documentation for reliability
• Liaise with other departments for research and intervention
• Perform other related duties as requested

Skills

Excel / Word / PowerPoint

Data analysis

Utilization management standards

Communication skills

Management / Supervisory

Attention to detail

Healthcare familiarity

Critical thinking

Education

Associate's Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

CareSource seeks a Manager of Utilization Management to oversee all utilization management activities, ensuring service consistency and meeting utilization targets. The role emphasizes coordination of pre-determination processes, data analysis, and regulatory compliance.

The position requires an RN license, a minimum of five years in clinical roles with UM/CM experience, and strong leadership. Massachusetts location with potential bonus based on performance is noted as part of a comprehensive