Utilization Management Lead (RN) — Regulatory Focus

Communityplans; California, Northern (MO, KY); Hybrid; USD 95,000 - 140,000; Full time

Job summary

Communityplans is seeking a Manager of Utilization Management in California to oversee UM functions, develop policies, and monitor quality. The role supervises the UM Supervisor and ensures compliance with DHCS, CMS, DMHC, NCQA standards and regulatory requirements.

The position requires RN licensure in California, 2+ years supervisory experience in managed care, and strong knowledge of UM processes. Proficiency with Outlook, Word, Excel and case management software is essential.

Qualifications

• RN licensure in California (required).
• Minimum two years in a supervisory role within a managed care setting.
• Understanding and/or experience with Utilization Management (UM).
• Knowledge of DHCS, CMS, DMHC regulations and NCQA Population Health standards.
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
• Proficient with Outlook, Word, Excel and case management programs.

Responsibilities

• Oversee internal and external delegated UM functions and policy development.
• Supervise the Supervisor of UM to ensure adherence to regulatory and organizational standards.
• Develop and implement procedures, program development and quality monitoring for UM.
• Ensure compliance with state and federal regulations and SCFHP policies.

Skills

RN licensure CA

Supervisory experience

Utilization Management

Regulatory knowledge (DHCS CMS DMHC NC

Accuracy & timeliness

Computer skills (Outlook Word Excel)

Tools

Outlook

Word

Excel

Case management software

Job description

Communityplans is seeking a Manager of Utilization Management in California to oversee UM functions, develop policies, and monitor quality. The role supervises the UM Supervisor and ensures compliance with DHCS, CMS, DMHC, NCQA standards and regulatory requirements.

The position requires RN licensure in California, 2+ years supervisory experience in managed care, and strong knowledge of UM processes. Proficiency with Outlook, Word, Excel and case management software is essential.