RN UM Director: Clinical Operations Leader

Imperial Health Plan of California, Inc.; Pasadena (CA); On-site; USD 120,000 - 160,000; Full time

Job summary

Imperial Health Plan of California, Inc. is seeking a Director of Utilization Management (UM) RN to lead the day-to-day UM/Prior Authorization and Inpatient teams, ensuring compliance with Federal, State, Health Plan and NCQA standards.

The role requires strategic oversight, staff development, and collaboration with clinical and non-clinical partners to maintain quality care and regulatory compliance. This exempt position reports to the Chief Medical Officer and demands strong leadership in a

Qualifications

• Bachelor’s degree in a health care related field.
• 5+ years management experience in a Medical Group, MSO, Hospital, or Health Plan setting with operational/production management.
• 5+ years of experience in UM/Managed Care setting

Responsibilities

• Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice.
• Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.
• Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.
• Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services
• Conduct inpatient huddles to review inpatient census including Inpatient CMs and CMO to discuss cases and discuss barriers of discharge plannings.
• Prepare and participate in UM audits.
• Develop and revising UM program, workplans and policies and procedures.
• Adheres to Compliance Plan and HIPAA regulations.

Skills

5+ years management experience

5+ years UM/Managed Care experience

RN licensure in California

Education

Bachelor’s degree in a health care related field

Tools

EZCap

Job description

Imperial Health Plan of California, Inc. is seeking a Director of Utilization Management (UM) RN to lead the day-to-day UM/Prior Authorization and Inpatient teams, ensuring compliance with Federal, State, Health Plan and NCQA standards.

The role requires strategic oversight, staff development, and collaboration with clinical and non-clinical partners to maintain quality care and regulatory compliance. This exempt position reports to the Chief Medical Officer and demands strong leadership in a