Utilization Management (UM) Manager

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 exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Job Summary

Acentra Health is looking for a Utilization Management Manager to join our growing team. The Manager of Utilization Management (UM) will ensure compliance, effective communication, and program success by coordinating staffing and operational structures. Their key role involves enhancing services, maintaining positive relationships, and identifying improvement opportunities in a focused approach.

Responsibilities

• Oversee, coordinate, and monitor clinical team activities, staffing, and operational performance to ensure achievement of program objectives and contractual service levels.
• Ensure compliance with applicable regulatory and accreditation requirements, including URAC standards, and provide appropriate compliance and oversight reporting.
• Establish and monitor clinical staff productivity, performance indicators, and other operational metrics.
• Assess workforce and skill requirements, identify gaps, and implement appropriate training and staff development initiatives to improve performance, problem-solving, and effectiveness.
• Develop and enhance Utilization Management operational structures, systems, and procedures, and advise leadership on opportunities for operational improvement.
• Manage assigned work plan objectives and projects to ensure timely completion.
• Collaborate with leadership in the development and enhancement of products and services.
• Represent the Utilization Management department on committees, task forces, workgroups, and multidisciplinary teams.
• Develop and maintain professional relationships with clients, providers, and external stakeholders, fostering ongoing communication to understand expectations, address concerns, and ensure program requirements are met.
• Identify opportunities for quality and performance improvement and develop and maintain quality improvement plans (QIPs) to support program success.
• Lead the management and maintenance of the Action Code Database, Universe Reports, and related databases, ensuring accurate and current data and timely reporting.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Required Qualifications

• Associate degree in Nursing (bachelor’s degree preferred)
• An active, unrestricted, Colorado Registered Nurse (RN) OR compact state license
• 5+ years of clinical experience
• 3+ years of staff and workload management experience
• 3+ years of experience in utilization management, claims, and appeals using criteria such as Milliman, InterQual, ASAM, or similar
• Experience in Medicare and Medicaid
• Expertise in one or more of the following areas: emergency medicine, medical/surgical, behavioral health, pediatrics, or cardiology

Preferred Qualifications

• Ability to work independently and collaboratively while contributing to departmental goals
• Strong organizational and prioritization skills, with the ability to adapt to change, manage multiple assignments, and meet competing deadlines
• Strong medical record abstraction and quality management skills
• Ability and willingness to develop subject matter expertise and serve as a thought leader for designated programs
• Knowledge of NCQA and URAC standards
• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Access

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

EEO AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Experience In Lieu Of Degree

For non-clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands-on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor's degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate's degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor's degree.

Compensation

The pay for this position is listed below.

"Based on our compensation philosophy, an applicant’s position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."

Pay Range

USD $99,600.00 - USD $120,000.00 /Yr.