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Manager, Utilization Review

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Personify Health

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Location:
United States

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Category:
Nursing

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Contract Type:
Employment contract

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Salary:

95000.00 - 105000.00 USD / Year
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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

Additional Information:

Job Posted:
May 16, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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