RN Utilization Management Lead — Healthcare Quality

CareSource

United States

On-site

USD 83,000 - 133,000

Full time

3 days ago

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Job summary

CareSource is seeking a Manager, Utilization Management in the United States to oversee all utilization management activities and ensure services align with utilization targets. The role focuses on coordinating pre-determination processes, maintaining regulatory compliance, and guiding data-driven decisions to improve member outcomes.

Ideal candidates bring RN licensure, 5+ years in clinical and utilization management areas, and strong leadership and analytical skills.

Qualifications

Associate’s Degree in Nursing is required.
BSN is preferred.

Responsibilities

Assist in coordination and management of the pre-determination process of medical and dental services and ensure criteria for authorization decisions.
Assist in developing integrated service delivery to members and oversee UM data and processes to meet standards and timeframes.
Interact with providers and staff to manage benefits aligned with state regulations, NCQA/URAC, and CareSource policies.
Review and revise workflows to maximize efficiencies.
Monitor productivity and utilization trends.
Oversee CQI activities and ensure audits and staff feedback occur regularly.