RN Utilization Management Lead — Elevate Member Care

CareSource; Northern (KY); Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Manager of Utilization Management to oversee all utilization management activities and ensure consistent service quality and achievement of targets. The role emphasizes leadership, regulatory compliance, and data-driven decision making.

Ideal candidates have an RN license with 5+ years in case management or utilization management, plus experience with CQI and interdepartmental collaboration. This on-site role offers a competitive compensation package and benefits.

Qualifications

• RN degree required; BSN preferred.
• Minimum five years in clinical settings with utilization/quality work.
• Experience in case management or managed care is beneficial.

Responsibilities

• Oversee pre-determination processes for medical and dental services.
• Ensure criteria are applied consistently for authorization decisions.
• Develop integrated service delivery and monitor utilization data.
• Interact with providers to align benefits with regulations and policies.
• Review workflows to maximize efficiency and monitor trends.
• Oversee CQI activities and audits with regular feedback.
• Report on regulatory requirements and maintain utilization data.
• Analyze under/over-utilization and suggest data-driven actions.

Skills

Utilization management knowledge

Data analysis

Leadership

Communication skills

Critical thinking

Attention to detail

Education

Associate Degree in Nursing

BSN preferred

Tools

Excel

Word

PowerPoint

Job description

CareSource is seeking a Manager of Utilization Management to oversee all utilization management activities and ensure consistent service quality and achievement of targets. The role emphasizes leadership, regulatory compliance, and data-driven decision making.

Ideal candidates have an RN license with 5+ years in case management or utilization management, plus experience with CQI and interdepartmental collaboration. This on-site role offers a competitive compensation package and benefits.