Senior Utilization Management Leader

Partnership HealthPlan of California; Fairfield (CA); On-site; USD 162,000 - 211,000; Full time

Job summary

Partnership HealthPlan of California is seeking a Director of Utilization Management to lead the Health Services department across product lines, ensuring compliant, effective health services programs and achievement of goals in a fast-paced environment.

The role directs UM staff, coordinates with Member Services, Claims and Provider Relations, and oversees reporting on activity, quality improvement, and utilization outcomes, including annual delegation audits.

Qualifications

• Bachelor’s degree in Nursing required.
• Minimum five (5) years of clinical experience; three (3) years of managed care experience; minimum three (3) years of management experience in a medical management setting.
• Working knowledge of ICD-CM and CPT coding; familiarity with Federal Medicaid/California Medi-Cal programs preferred.

Responsibilities

• Provide day-to-day direction to Utilization Managers and Supervisors to meet department goals.
• Ensure timely performance evaluations and participate in grievance processes.
• Coordinate with Member Services, Claims, and Provider Relations to monitor quality of care and trends.
• Produce annual or on-demand reports with utilization outcomes and quality improvement data.
• Oversee medical claims review/appeals and ensure timely, accurate responses.
• Collaborate across departments to resolve UM, claims, and provider issues.
• Lead training content development for new staff and ongoing education.

Skills

Leadership

Analytical skills

Telephone and computer skills

Medical management software

ICD-CM/CPT coding

Education

Bachelor’s degree in Nursing

California Registered Nurse license

Tools

PCs

Job description

Partnership HealthPlan of California is seeking a Director of Utilization Management to lead the Health Services department across product lines, ensuring compliant, effective health services programs and achievement of goals in a fast-paced environment.

The role directs UM staff, coordinates with Member Services, Claims and Provider Relations, and oversees reporting on activity, quality improvement, and utilization outcomes, including annual delegation audits.