RN Clinical Ops Lead: Utilization Management & Quality

Advanced Medical Management, Inc.; Long Beach (CA); Hybrid; USD 110,000 - 140,000; Full time

Benefits offered by this job

Health coverage

HMO and PPO options

Vision and dental premiums

Job summary

Advanced Medical Management, Inc. seeks a Clinical Services Manager to oversee Utilization Management, clinical auditing and quality improvement.

You will provide operational and clinical leadership to ensure efficient authorization processes and regulatory compliance. You will collaborate with Case Management, Quality Management, Provider Relations, Claims, Compliance and IT to advance patient care, value-based initiatives, and performance excellence in a hybrid/office-based California

Qualifications

• RN license and active California license required.
• BSN degree required; MSN preferred.
• Minimum 5 years in Utilization Management or Clinical Operations.
• 2+ years of leadership or supervisory experience.
• Experience with CMS/DMHC audits is highly preferred.

Responsibilities

• Oversee daily UM operations including prior authorization review workflows and turnaround time compliance.
• Monitor authorizations to ensure CMS/DMHC/NCQA standards.
• Develop and monitor UM policies, procedures, and workflows.
• Collaborate with Medical Directors and providers on medical necessity criteria and escalation.
• Lead internal clinical audit activities and ensure documentation compliance.
• Track KPIs and drive process improvements in operations and quality.
• Supervise UM nurses, coordinators, and clinical staff; support staff development.

Skills

Leadership

Regulatory knowledge

Data analysis

Communication

UM processes

Education

Registered Nurse (RN) license

BSN

MSN preferred

Tools

UM platforms

EMR systems

Microsoft Office

Job description

Advanced Medical Management, Inc. seeks a Clinical Services Manager to oversee Utilization Management, clinical auditing and quality improvement.

You will provide operational and clinical leadership to ensure efficient authorization processes and regulatory compliance. You will collaborate with Case Management, Quality Management, Provider Relations, Claims, Compliance and IT to advance patient care, value-based initiatives, and performance excellence in a hybrid/office-based California