Utilization Management Leader – Health Plan

County of Contra Costa; Martinez (CA); On-site; USD 130,000 - 165,000; Full time

Job summary

Contra Costa Health Plan is seeking a strategic Utilization Review Manager in Martinez, CA. You will lead clinical review operations, drive policies, and ensure compliant, timely utilization management for multiple lines of business.

Ideal candidates bring RN licensure in California, 3 years in hospital managed care UR roles, plus 1 year supervisory experience. Mastery of DHCS/DMHC/CMS/NCQA standards is preferred.

Qualifications

• RN with a nursing license in California.
• Experience leading utilization review functions in managed care.
• Familiarity with DHCS, DMHC, CMS, and NCQA standards.

Responsibilities

• Oversee day-to-day clinical review operations and authorizations.
• Develop and implement utilization management policies and workflows.
• Ensure compliance and timely member/provider notifications.
• Prepare for audits by CMS/DMHC and delegated UM reviews.
• Collaborate with internal/external partners to support coordinated care.
• Develop reports and tools to drive accountability.

Skills

Leadership

Regulatory knowledge

People management

Policy implementation

Data-driven decision making

Education

Bachelor's degree in nursing

Tools

None

Job description

Contra Costa Health Plan is seeking a strategic Utilization Review Manager in Martinez, CA. You will lead clinical review operations, drive policies, and ensure compliant, timely utilization management for multiple lines of business.

Ideal candidates bring RN licensure in California, 3 years in hospital managed care UR roles, plus 1 year supervisory experience. Mastery of DHCS/DMHC/CMS/NCQA standards is preferred.