Utilization Management Lead - RN, Compliance & Ops

Acentra Health; United States; On-site; USD 100,000 - 120,000; Full time

Benefits offered by this job

Health plans

Paid time off

Retirement savings

Corporate wellness

Educational assistance

Corporate discounts

Job summary

Acentra Health seeks a Utilization Management Manager to lead clinical team activities, ensuring regulatory compliance and program success. You will coordinate staffing, monitor performance, and drive improvements across UM operations.

In this role you will collaborate with leadership to enhance products and services, maintain strong relationships with clients, and ensure timely reporting while upholding HIPAA privacy and security standards.

Qualifications

• Active RN license (Colorado or compact state)
• 5+ years of clinical experience
• 3+ years staff and workload management experience
• 3+ years of utilization management, claims, and appeals experience using Milliman, InterQual, ASAM, or similar
• Experience with Medicare and Medicaid

Responsibilities

• Oversee clinical team activities, staffing, and performance to meet objectives and service levels.
• Ensure compliance with regulatory/accreditation requirements (URAC, HIPAA) and provide oversight reporting.
• Establish productivity and performance indicators for clinical staff.
• Identify gaps in workforce and implement training and development initiatives.
• Develop and enhance UM structures, systems, and procedures; advise leadership on improvements.
• Manage work plan objectives and projects to ensure timely completion.
• Collaborate with leadership to develop products and services.
• Represent UM on committees and multidisciplinary teams.
• Maintain relationships with clients, providers, and stakeholders to meet program requirements.
• Identify quality and performance improvement opportunities and maintain QIPs.
• Lead the management of data systems and reporting (e.g., databases) with accuracy and timeliness.
• Read, understand, and adhere to corporate policies including HIPAA/privacy rules.

Skills

Staff management

Utilization management

Regulatory compliance

HIPAA knowledge

Medicare/Medicaid understanding

Education

Associate degree in Nursing

RN license (Colorado or compact state)

Bachelor’s degree preferred

Tools

Milliman criteria

InterQual criteria

ASAM criteria

Job description

Acentra Health seeks a Utilization Management Manager to lead clinical team activities, ensuring regulatory compliance and program success. You will coordinate staffing, monitor performance, and drive improvements across UM operations.

In this role you will collaborate with leadership to enhance products and services, maintain strong relationships with clients, and ensure timely reporting while upholding HIPAA privacy and security standards.