Manager, Clinical Utilization Management

RSC Solutions

🇺🇸 United States
On-site
Manager or above
1 day ago

prior authorization
CMS
RN License

1 day ago

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The Manager, Utilization Management (UM) is responsible for providing strategic leadership and operational oversight for both inpatient and outpatient utilization management clinical teams, including prior authorization, concurrent review, and care coordination functions. This role is accountable for driving clinical quality outcomes, reducing medical loss ratio (MLR), decreasing avoidable admissions and readmissions, and aligning utilization management activities with organizational quality metrics and regulatory requirements.

The Manager ensures appropriate utilization of healthcare services across the continuum of care, with a strong focus on proactive discharge planning, high‐risk population management, and interdisciplinary collaboration. This position partners closely with Case Management, High Risk Care Management, Pharmacy, Medical Directors, and Clinical Operations to develop clinical solutions that optimize patient outcomes while maintaining cost‐effective care delivery.

This role also participates in a rotational management on‐call program, providing leadership support during after‐hours and weekend periods as needed.

Essential Position Functions/Responsibilities:

Provide strategic and operational leadership for inpatient and outpatient utilization management teams
Oversee Prior Authorization, Concurrent Review, and Inpatient Utilization functions
Manage clinical staff across UM teams
Establish departmental goals aligned with organizational strategic objectives
Promote a culture of accountability, collaboration, and continuous improvement
Ensure staff adherence to policies, procedures, and regulatory requirements
Conduct performance evaluations, coaching, and professional development planning
Maintain appropriate staffing models to support operational efficiency and service levels
Monitor and analyze utilization data to identify trends, opportunities, and performance gaps
Drive initiatives to reduce admissions, readmissions, and unnecessary utilization
Implement strategies to reduce medical loss ratio (MLR) while maintaining quality outcomes
Ensure alignment with clinical quality metrics and population health initiatives
Oversee appropriate application of clinical criteria including MCG and payer guidelines
Audit utilization decisions for clinical appropriateness and compliance
Evaluate and improve workflows to enhance operational efficiency
Monitor turnaround time, productivity, and key performance indicators
Lead development and monitoring of utilization management programs
Partner with Director of Pharmacy to develop clinical solutions and optimize medication utilization
Collaborate with High Risk Care Management team to address complex populations
Work closely with Medical Directors to support clinical decision making
Coordinate and develop with Case Management leadership and Social Work Team alignment of organizational and departmental goals that full align with the SVP of Clinical Services
Collaborate with Quality, Pharmacy, and Appeals teams
Participate in Utilization Management Committee
Ensure compliance with CMS, NCQA, State, Federal, and Department of Labor requirements
Maintain regulatory readiness and audit preparedness
Lead internal audits and quality improvement initiatives
Develop and maintain policies, procedures, and standard operating procedures
Participate in external and internal audits as subject matter expert
Develop and monitor departmental KPIs
Prepare weekly and monthly utilization reports
Analyze utilization trends and financial impact
Provide leadership reporting and recommendations
Monitor turnaround times and productivity metrics
Provide day‐to‐day operational oversight for inpatient and outpatient teams
Monitor staffing productivity and workflow efficiency
Implement process improvements and operational initiatives
Support implementation of new programs and technologies
Participate in strategic planning initiatives
Participate in rotational management on‐call schedule
Provide leadership coverage during evenings, weekends, and holidays
Support escalation management and operational decision making

Qualification Requirements:
Skills, Knowledge, Abilities

Strong knowledge of Utilization Management principles
Knowledge of MCG, CMS, NCQA, and regulatory requirements
Understanding of Medicare, Medicaid, and Commercial payer guidelines
Experience with care coordination and transitions of care
Strong analytical and problem‐solving skills
Excellent communication and leadership skills
Ability to manage multiple priorities in a fast‐paced environment
Strong organizational and time management skills
Ability to lead change and drive performance improvement
Experience with quality improvement initiatives
Ability to build collaborative relationships across departments

Training/Education:

Bachelor of Science in Nursing (BSN) required
Master's degree in Nursing, Healthcare Administration, or related field preferred
Active, unrestricted Registered Nurse (RN) license required

Experience:

Minimum five (5) years of clinical experience required
Minimum three (3) years of leadership or supervisory experience required
Utilization Management experience in Managed Care required
Inpatient Utilization Management experience preferred
Prior Authorization experience preferred
Experience managing interdisciplinary teams preferred

Manager, Clinical Utilization Management · RSC Solutions

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