Utilization Management Lead: Quality & Compliance

Sky Mavis; Tucson (AZ); Hybrid; USD 100,000 - 140,000; Full time

Job summary

P3 Health Partners is seeking a seasoned Utilization Management Manager to oversee the UM department and drive quality, efficiency, and compliance. You will lead a team of UM professionals, collaborate with clinical and operational stakeholders, and influence processes that improve patient outcomes and healthcare value.

You will mentor staff, participate in audits, and contribute to strategic planning and organizational growth.

Qualifications

• Graduate of an accredited school of nursing.
• Active, unrestricted RN license in AZ, CA, NE, NV or OR.
• Ability to obtain licensure in all delegated markets within one year of hire.
• Minimum of five (5) years of clinical nursing experience.
• Minimum of two (2) years of experience within managed care, an HMO, or a global risk-bearing provider organization.
• Minimum of two (2) years of supervisory or management experience.
• Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.

Responsibilities

• Lead and manage the daily operations of the Utilization Management department, including staff supervision, coaching, and performance management.
• Monitor departmental workflows to ensure efficiency, accuracy, and compliance with applicable regulations and organizational requirements.
• Serve as a subject matter expert and resource for UM staff, providing ongoing education, mentorship, and support.
• Promote a culture of quality, accountability, and continuous improvement across the department.
• Participate in Utilization Management and Quality Assurance committees and support organizational quality initiatives.
• Assist with preparation for and participation in audits conducted by health plans, NCQA, CMS, and other regulatory entities.
• Collaborate with cross-functional teams including Case Management, Clinical Operations, Quality Improvement, Claims, Network Development, Configuration, and Finance.
• Develop, implement, and maintain departmental policies, procedures, and workflow standards.
• Identify process improvement opportunities and provide recommendations for system enhancements and operational efficiencies.
• Maintain expertise in Medicare Advantage regulations, managed care requirements, and provider/facility contract provisions.
• Partner with Medical Directors to support medical necessity determinations and coordination of care activities.
• Participate in strategic planning, budgeting activities, and organizational growth initiatives.
• Support implementation efforts related to new markets, programs, and business expansion.

Skills

Leadership

Regulatory knowledge

Communication

Project management

MS Office

Education

Accredited nursing program

BSN preferred

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Outlook

Job description

P3 Health Partners is seeking a seasoned Utilization Management Manager to oversee the UM department and drive quality, efficiency, and compliance. You will lead a team of UM professionals, collaborate with clinical and operational stakeholders, and influence processes that improve patient outcomes and healthcare value.

You will mentor staff, participate in audits, and contribute to strategic planning and organizational growth.