Manager, Utilization Review Job at Personify Health

Job Description

Manager, Utilization Review for Care Management, remote in the United States. Personify Health is a personalized health platform. Responsibilities include supervising Utilization Management staff, people management, coaching, auditing, and ensuring compliance. Multiple levels (I, II, Senior) with increasing responsibilities.

Job Responsibility

Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows
Provide full people management for assigned Utilization Management teams, including hiring, performance management, and staff development
Provide routine coaching, feedback, auditing, support and disciplinary action to ensure productivity, quality, and timeliness standards are met
Participate in hiring, onboarding, and training of Utilization Management staff
Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements
Escalate clinical, operational, and performance issues appropriately to leadership
Reinforce policies, procedures, and clinical guidelines through regular communication and staff education
Support audit readiness by ensuring staff compliance with documentation and timeliness standards
Maintain HIPAA compliance, confidentiality, and minimum necessary access at all times
Solid knowledge and understanding of medical necessity criteria across inpatient, outpatient, concurrent, and retrospective reviews, with the ability to coach staff on clinical rationale, documentation quality and timeliness
Drive team performance against key metrics, including engagement, productivity, quality scores, and turnaround times
Analyze operational and quality data to identify trends, gaps, and opportunities for improvement
Lead documentation audits and implement corrective actions to ensure regulatory and accreditation compliance
Collaborate with cross-functional partners (CM, CDM, Appeals, Provider Relations, Quality, and Operations) to resolve issues and improve care coordination
Support implementation of workflow changes, new programs, or system enhancements
Ensure consistent application of policies, clinical criteria, and plan language across the team
Prepare team for internal and external audits (e.g., NCQA, URAC) and support responses to findings
Serve as a subject matter resource for staff and peers related to Case Management operations and standards
Provides strategic leadership and oversight for UM operations across multiple teams or functions
Serves as a senior subject matter expert in utilization review, regulatory compliance, and clinical operations
Leads complex initiatives involving process redesign, system optimization, and performance improvement
Partners with executive and cross-functional leaders to align UM strategy with organizational goals
Oversees achievement of performance guarantees, audit readiness, and sustained regulatory compliance
Interprets and applies advanced regulatory, legal, and accreditation requirements, providing guidance to leadership and staff
Mentors and develops managers, supporting leadership growth and succession planning
Analyzes enterprise-level performance metrics and trends to drive data-informed decision-making
Leads change management efforts and promotes adoption of best practices and innovation
Represents the organization in external audits, regulatory discussions, and stakeholder engagements as needed
Compliance and efficiency expert in URAC, NCQA, ERISA, and legal requirements

Requirements

Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable)
Graduate of an accredited nursing program (ADN or diploma required
BSN preferred)
Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
1-2 years in care management, utilization management, discharge planning, or related clinical coordination
Minimum 1 year of compliance related experience preferred
Certification in Case Management or Utilization Review preferred but not required
1+ year of informal leadership (preceptor/mentor/lead) or some direct people leadership
Working understanding of HIPAA, member rights, scope of practice, and documentation requirements
Comfort following policies and escalating risk/safety concerns appropriately
Coaching fundamentals (1:1s, feedback, basic performance support)
Strong written communication (member notes, provider communications)
Basic data literacy: productivity, caseload management, simple reports/dashboards
Conflict de-escalation and customer service mindset (members/providers)
Certification in relevant field preferred
3+ years in care management or closely related clinical operations
3+ years managing a Utilization Management team (or multiple pods/teams)
Evidence of initiating and leading process improvement and implementations
Critical Thinking with the understanding of efficient workflows
Ownership of KPIs: engagement, outreach effectiveness, transitions of care, closure rates, care gap support
Staffing and workflow optimization (queue management, triage rules, prioritization)
Ability to standardize documentation, audit quality, and reduce variation
Practical understanding of audit readiness (internal audits, corrective action plans)
Experience interpreting and operationalizing policies, UM/CM timeliness expectations, and documentation standards as it relates to accreditation
Ability to lead through change and reinforce consistent practice models
Works effectively with UM, provider relations, claims, appeals/grievances, pharmacy, behavioral health, and vendor partners
Strong provider communication skills and escalation management
Master's Degree strongly preferred
5 years progressive experience in CM/health plan clinical operations, population health, or complex care
5+ years people leadership, including managers/supervisors or multi-site leadership
Owns program design and execution: Platform design and implementation
Drives measurable outcomes: TAT adherence, audit compliance
Budget planning, staffing models, productivity forecasting, vendor management
Ability to build business cases and evaluate ROI of interventions and tools
Leads audit readiness and corrective actions across teams
Sets policy interpretation, standard operating procedures, and controls to reduce risk
Presents to senior leadership, creates dashboards/storytelling with data
Strong negotiation and influence across departments and with providers/vendors
Leads large transformations (new platforms, workflow redesign, reorganizations, new regulatory requirements)
Develops leadership bench strength (succession planning, manager development)
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Ability to work independently and utilize written resources to problem solve
Ability to work independently within appropriate programs after training
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations

Nice to have

Certification in Case Management or Utilization Review preferred but not required
Minimum 1 year of compliance related experience preferred
BSN preferred
Master's Degree strongly preferred

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions
Unlimited PTO
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets

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Manager, Utilization Review

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