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Duties/Responsibilities:

+ Provide strategic oversight and operational management for all utilization management functions, including prior authorization, concurrent review, and service requests

+ Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators

+ Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities

+ Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance

+ Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments

+ Utilize data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation

+ Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management

+ Foster a culture of accountability, professional development, and continuous improvement across all levels of the team

+ Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment

+ Support system implementations and technology enhancements to improve automation, reporting, and member/provider experience

+ Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards

+ Additional duties as assigned

Minimum Qualifications:

+ Bachelors degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience

+ NYS RN

+ Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations

+ Leadership experience in managing, coaching and developing multidisciplinary clinical team

+ Strong analytical, organizational, and problem-solving skills

+ Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions

+ Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment

Preferred Qualifications:

+ Prior experience leading a team of people leaders

+ Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.

+ Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS

+ Experience working and//or managing in a virtual environment

+ Understanding of health plans such as Medicare, Medicaid and//or Managed Long-Term Care Plan (MLTCP)

+ Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC

+ Strong understanding of value-based care principles and their application to MLTC populations

+ Experience accessing and maintaining patient health information (PHI) electronically in a shared network

+ Strong computer skills, including, but not limited to word processing, spreadsheets, and databases

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.