Job Description
Job Description
COMPANY OVERVIEW:
Our client is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. They will transform the way healthcare is administered in the United States by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.
PURPOSE AND SCOPE:
The Senior Manager, Utilization Management (UM), is responsible for leading the day-to-day operations of the Utilization Management Department, including Prior Authorizations, Inpatient, and Skilled Nursing Facility Concurrent Review.
This role drives operational excellence, compliance, and innovation by leveraging AI-enabled tools and data analytics to enhance clinical decision-making, streamline review processes, and optimize member outcomes. The Senior Manager partners closely with the BPO Operations leadership to ensure the UM function aligns with regulatory standards, payer expectations, and organizational performance goals.
PRINCIPAL RESPONSIBILITIES AND DUTIES
Leadership & Operations
- Lead and oversee all activities related to Prior Authorization and Concurrent Review operations.
- Supervise, mentor, and develop a team of nurses, coordinators, and support staff to achieve department goals and service-level standards.
- Establish measurable team and individual performance goals; provide ongoing coaching, feedback, and performance evaluations.
- Manage staffing, scheduling, and productivity to meet CMS timeliness and compliance requirements.
- Collaborate with senior leadership to set departmental strategy and key performance metrics aligned with business objectives.
AI Innovation & Process Optimization
- Champion the adoption and optimization of AI and automation tools that improve utilization review accuracy, turnaround time, and efficiency.
- Partner with internal technology teams to pilot and implement AI-driven solutions for case triage, predictive analytics, and workflow automation.
- Use data insights from AI dashboards and reporting tools to identify trends, forecast utilization, and recommend process improvements.
- Train staff on AI-supported workflows, ensuring ethical and compliant use of technology to enhancenot replaceclinical judgment.
- Collaborate with data science and IT teams to evaluate emerging technologies that can strengthen prior authorization efficiency, reduce administrative burden, and improve provider/member satisfaction.
Compliance & Quality
- Ensure adherence to federal, state, and accreditation requirements (CMS, NCQA, URAC, etc.).
- Maintain departmental policies, procedures, and documentation consistent with Plan requirements and audit readiness.
- Monitor quality metrics, perform audits, and implement corrective actions as needed.
- Coordinate closely with the others on clinical oversight and quality improvement initiatives.
Reporting & Communication
- Oversee all departmental reports and performance metrics, ensuring accuracy and timely delivery to leadership.
- Provide clear communication and updates across teams and to leadership regarding departmental progress and challenges.
- Cultivate a culture of continuous improvement, transparency, and innovation.
Customer Service
- Model and promote the company values and customer service standards.
- Build strong, collaborative relationships with internal and external stakeholders.
- Proactively address and resolve service issues, ensuring an exceptional experience for members, providers, and partners.
EDUCATION, EXPERIENCE AND REQUIRED SKILLS:
- Florida licensed (or compact) RN or LPN required (RN preferred)
- Baccalaureate degree from an accredited institution of higher learning preferred
- Three to five years related Medicare/Medicaid HMO experience at the managerial level required
- An equivalent combination of education, training and experience.
- Ability to navigate and master proprietary software programs.
- Prior experience implementing or managing technology-enabled UM tools (AI-assisted review, workflow automation, or predictive analytics) preferred.
- Excellent oral and written communication skills including good grammar, voice and diction.
- Able to read and interpret documents.
- Proficient in MS Office with basic computer and keyboarding skills.
- Strong skills in investigation and resolution of issues pertaining to internal and external clients.
- Ability to develop a capable, cohesive and harmonious working team that strives for excellence in quality of all services provided.
For the area of Inpatient and Skilled Nursing Concurrent Review:
- Experience in discharge planning from Inpatient Acute Care Facilities to other levels of post inpatient care.
- Strong understanding and implementation of Medicare criteria as it relates to Skilled Nursing Facility care.
- Strong knowledge base of Medicare and Medicaid coverage criteria and compliance requirements.