Senior RN Leader, Utilization Management

Imperial Health Plan of California, Inc.; Pasadena (CA); On-site; USD 140,000 - 180,000; Full time

Job summary

Imperial Health Plan of California, Inc. is seeking a Director of Utilization Management (UM) to lead the day-to-day UM/Prior Authorization and Inpatient teams.

The role ensures compliance with Federal, State, Health Plan, and NCQA standards, while providing operational leadership and strategic direction. You will collaborate with clinical and non-clinical staff, develop policies, monitor performance, and drive continuous improvement in medical necessity reviews, discharge planning, and program

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 experience in operational/production management
• At least 5 years of experience in UM/Managed Care setting
• EZCap experience

Responsibilities

• Provide operational leadership to the day-to-day UM/Prior Authorization and Inpatient teams.
• Ensure compliance with Federal, State, Health Plan and NCQA standards.
• Train staff on medical necessity reviews and documentation.
• Document reviews timely with supporting information and criteria.
• Monitor referral patterns and report to UM Medical Director.
• Lead audits and develop UM programs, workplans and policies.

Skills

Microsoft Suite

English proficiency

Leadership

Regulatory knowledge

UM/Managed Care

Education

Bachelor’s degree in a health care related field

Tools

EZCap

Job description

Imperial Health Plan of California, Inc. is seeking a Director of Utilization Management (UM) to lead the day-to-day UM/Prior Authorization and Inpatient teams.

The role ensures compliance with Federal, State, Health Plan, and NCQA standards, while providing operational leadership and strategic direction. You will collaborate with clinical and non-clinical staff, develop policies, monitor performance, and drive continuous improvement in medical necessity reviews, discharge planning, and program