RN Utilization Management Director — Lead & Elevate Care

Imperial Health Plan of California, Inc.; Pasadena (CA); On-site; USD 140,000 - 200,000; Full time

Job summary

Imperial Health Plan of California, Inc. seeks a Director of Utilization Management (RN) to lead the UM, Prior Authorization and Inpatient Teams and ensure compliance with Federal, State, Health Plan and NCQA requirements.

The Director will provide operational leadership, oversee staff performance, training, audits and program development, and collaborate with the Chief Medical Officer to optimize care delivery and compliance across UM activities.

Qualifications

• Bachelor’s degree in a health care related field.
• 5+ years of management experience in a Medical Group, MSO, Hospital, or Health Plan setting with operational/production management.
• 5+ years of UM/Managed Care experience.
• EZCap experience.
• RN licensure in CA (required) with multi-state licenses a plus.

Responsibilities

• Lead the day-to-day UM/Prior Authorization and Inpatient teams ensuring compliance with clinical standards.
• Ensure timely care and adherence to Federal, State, Health Plan and NCQA requirements.
• Oversee staff scheduling, reviews, and performance against policy.
• Train UM team on medical necessity reviews and documentation.
• Prepare audits and compliance reports; participate in MSC and other meetings.

Skills

Microsoft Suite

Education

Bachelor’s degree in a health care related field

Tools

EZCap

Job description

Imperial Health Plan of California, Inc. seeks a Director of Utilization Management (RN) to lead the UM, Prior Authorization and Inpatient Teams and ensure compliance with Federal, State, Health Plan and NCQA requirements.

The Director will provide operational leadership, oversee staff performance, training, audits and program development, and collaborate with the Chief Medical Officer to optimize care delivery and compliance across UM activities.