Utilization Management (UM) Program Manager

The Utilization Management (UM) Program Manager plays a vital
role in driving the strategic planning, execution, and continuous enhancement
of UM programs. The position ensures the delivery of clinically appropriate and
cost-effective care by optimizing utilization management processes across the
organization.

Key Responsibilities:

• Lead and manage UM programs to align with organizational
  goals for quality, efficiency, and compliance.
• Collaborate closely with clinical UM, Care
  Management, Quality, Information Technology (IT), and other key stakeholders,
  to streamline authorization workflows and improve operational efficiency
• Develop and implement strategies to reduce avoidable
  denials and enhance patient throughput
• Ensure adherence to regulatory and accreditation
  standards through Effective program oversight and compliance monitoring
• Coordinate complex, multi work stream
  initiatives that involve cross functional teams
• Utilize data analytics to inform decision
  making, identify opportunities for improvement, and measure program outcomes
• Standardize UM processes, tools, and
  documentation to promote consistency and scalability
• Facilitate communication and change management
  efforts to support successful program adoption and sustainability
• Support other clinical departments as needed to advance organizational objectives

Required:

• Bachelor's
  degree in healthcare administration, business, public health, or a related field
  and/or equivalent experience
• 5+ years
  of related experience or training in healthcare operations, utilization
  management, care management, quality, revenue cycle, contracting, or related
  operational/program work
• 3+ years of experience leading cross functional
  projects or programs that include workflow improvement, stakeholder
  coordination, and measurable outcomes (may be included within the 5+ years)
• Strong analytical skills to define metrics,
  interpret trends, and translate findings into action plans
• Ability to communicate clearly in writing and
  verbally with clinicians, administrators, and technical partners
• Facilitate work groups and meetings effectively
  including agendas, decision capture, and follow up tracking
• Uses sound judgment to prioritize work, manage competing
  deadlines and raise risks early
• Ability to build collaborative relationships
  across departments and supports constructive resolution of workflow issues
• Designs scalable workflows, documentation, and
  controls that support consistent operations and sustainment
• Maintains discretion and protects sensitive
  information learned through work activities

Preferred

• Master's degree (MPH, MHA, MSN, MBA) or equivalent
  advanced training
• Demonstrates working knowledge of UM workflows
  such as prior authorization, concurrent review, and denials/appeal.
• Uses UM tools and reporting methods (e.g. InterQual/MCG, authorization platforms, self-service
  reporting) to support outcomes