RN Utilization Management Lead — Data-Driven Care

CareSource; United States; Remote; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Manager, Utilization Management to oversee utilization activities and ensure consistency of services to meet utilization targets.

Responsibilities include coordinating the pre-determination process, ensuring decisions involve qualified clinicians, and leading CQI and regulatory reporting.

The role collaborates with providers and staff to manage benefits per regulatory standards while driving data-informed improvements in member outcomes.

Qualifications

• RN licensure in state of practice required.
• Minimum 5 years of clinical experience.
• Minimum 5 years of experience in case management, utilization management, and/or quality improvement.
• Two years of utilization management experience preferred.
• Managed care experience preferred.

Responsibilities

• Oversee pre-determination process for medical and dental services; ensure consistent criteria for authorization decisions.
• Develop integrated service delivery to members and oversee utilization management data and processes.
• Interact with providers and staff to align benefits with regulations and policies.
• Review and revise workflows to maximize efficiencies.
• Monitor productivity and utilization trends.
• Oversee CQI activities and ensure audits and staff feedback occur regularly.

Skills

Excel basics

Data analysis

Communication skills

Leadership

Time management

Independent worker

Education

Associate’s Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

CareSource is seeking a Manager, Utilization Management to oversee utilization activities and ensure consistency of services to meet utilization targets.

Responsibilities include coordinating the pre-determination process, ensuring decisions involve qualified clinicians, and leading CQI and regulatory reporting.

The role collaborates with providers and staff to manage benefits per regulatory standards while driving data-informed improvements in member outcomes.