Utilization Management Lead - Clinical Ops and Compliance

Acentra; Northern (KY); Hybrid; USD 100,000 - 120,000; Full time

Job summary

Acentra Health is seeking a Manager of Utilization Management to lead the UM team, ensure compliance, and drive program success through coordinated staffing and operations. You will oversee clinical activities, monitor productivity and performance, identify improvement opportunities, and collaborate with leadership to enhance products and services for Medicare and Medicaid populations.

This role requires a nursing background with regulatory knowledge (URAC, NCQA) and a track record of improving

Qualifications

• Active, unrestricted Colorado RN license or compact state license
• 5+ years of clinical experience
• 3+ years of staff and workload management experience
• 3+ years of utilization management experience (claims/appeals)
• Experience with Medicare and Medicaid
• Expertise in emergency medicine, medical/surgical, behavioral health, pediatrics, or cardiology

Responsibilities

• Oversee clinical team activities, staffing, and performance to meet objectives
• Ensure regulatory and accreditation compliance (URAC, HIPAA)
• Monitor productivity and performance indicators of clinical staff
• Identify gaps and implement training to improve performance
• Develop and improve Utilization Management operational structures and procedures
• Lead assigned work plans and projects to timely completion
• Collaborate with leadership to enhance products and services
• Represent UM on committees and cross-functional teams
• Maintain relationships with clients, providers, and external stakeholders
• Establish quality improvement plans to support program success
• Maintain data in Action Code Database, Universe Reports, and related databases
• Read and adhere to HIPAA policies

Skills

Strong organizational skills

Independent and collaborative work

NCQA and URAC knowledge

Education

Associate degree in Nursing

Bachelor’s degree preferred

Job description

Acentra Health is seeking a Manager of Utilization Management to lead the UM team, ensure compliance, and drive program success through coordinated staffing and operations. You will oversee clinical activities, monitor productivity and performance, identify improvement opportunities, and collaborate with leadership to enhance products and services for Medicare and Medicaid populations.

This role requires a nursing background with regulatory knowledge (URAC, NCQA) and a track record of improving