Senior Manager, Vendor Utilization & Care Management

Transformcap; United States; On-site; USD 95,000 - 130,000; Full time

Job summary

Transformcap is seeking an RN-licensed leader to oversee vendors delivering utilization management, care management, and clinical operations. You will ensure medical necessity and appropriate care levels while coordinating with medical leadership on complex cases and policy development.

You will supervise prior authorization, peer‑to‑peer reviews, denials and appeals, HRAs, chronic disease programs, and transitions of care, ensuring compliance with URAC/NCQA and payer systems.

Qualifications

• Active unrestricted RN license ( BSN preferred )
• 5+ years of experience in utilization management, care management, or case management
• 2+ years of leadership experience
• Knowledge of medical necessity reviews, care coordination models, and payer systems

Responsibilities

• Provide oversight for vendors conducting utilization management, care management, and clinical operations activities.
• Oversee vendor execution of utilization reviews to ensure medical necessity and appropriate level of care determinations.
• Monitor vendor review of medical records and treatment plans to support appropriate service utilization and optimize reimbursement outcomes.
• Partner with Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations.
• Provide oversight of vendor‑managed prior authorization, peer‑to‑peer review, denial, appeal, and notification processes.
• Ensure vendors complete comprehensive biopsychosocial assessments and HRAs in accordance with program requirements.
• Oversee vendor‑led care coordination across the continuum, including transitions of care and discharge planning.
• Provide oversight of vendor‑administered chronic disease and complex case management programs.
• Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care.
• Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented.
• Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements.
• Coordinate with vendor interdisciplinary teams to promote aligned clinical operations and member outcomes.
• Promote vendor‑delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes.

Skills

Utilization management

Care management

Leadership

Medical necessity reviews

Payer systems

Education

RN license (BSN preferred)

Job description

Transformcap is seeking an RN-licensed leader to oversee vendors delivering utilization management, care management, and clinical operations. You will ensure medical necessity and appropriate care levels while coordinating with medical leadership on complex cases and policy development.

You will supervise prior authorization, peer‑to‑peer reviews, denials and appeals, HRAs, chronic disease programs, and transitions of care, ensuring compliance with URAC/NCQA and payer systems.