Nurse Care Manager • Lead

Who you are

You are a seasoned healthcare professional with a strong background in utilization management and operational leadership. You have experience ensuring compliance with accreditation standards and regulatory obligations, and you understand the importance of evidence-based medical necessity criteria. Your leadership skills enable you to effectively manage UM staff and workflows, ensuring that prior authorization, concurrent review, and retrospective review processes are executed efficiently.

You possess excellent communication skills, allowing you to convey complex information clearly to both your team and stakeholders. Your ability to analyze performance metrics and implement continuous improvement strategies is key to maintaining high standards in UM operations. You are committed to fostering a culture of compliance and quality within your team, ensuring that all activities align with contractual requirements.

What you'll do

In this role, you will be responsible for the operational leadership of Utilization Management programs across various contracts and lines of business. You will oversee the UM staff, ensuring that workflows related to prior authorization, concurrent review, and medical necessity determinations are executed in a timely and compliant manner. Your focus will be on maintaining quality and compliance while meeting budgetary and performance expectations.

You will lead initiatives aimed at improving the efficiency and effectiveness of UM operations, utilizing data-driven insights to inform decision-making. Your role will involve regular performance management, ensuring that staff competencies are aligned with the demands of the UM processes. You will also be accountable for peer review processes and denial communications, ensuring that all actions taken are in accordance with established guidelines and best practices.

What we offer

At Telligen, we value our employees and offer a supportive work environment that encourages professional growth. You will have the opportunity to work with a dedicated team focused on improving healthcare outcomes through effective utilization management. We provide competitive compensation and benefits, along with opportunities for continued education and training in the healthcare field.