Responsibilities

Ready To

What You'll Actually Do

ESSENTIAL DUTIES and RESPONSIBILITIES:

Level I

· 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.

Level II

· Same as above

· 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.

· Demonstrated ability to work independently with excellent judgment and consistent application of regulatory requirements.

· Utilizes analytical and problem-solving skills to identify and review pertinent information and create action plans

· Serves as an interdepartmental company and external group resource

· Identifies gaps in process and policies compliance issues and implements solutions

· Acts as a Change Champion

Senior

· Same as Level I and Level II

· 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

KEY COMPETENCIES:

To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions

UPON HIRE, must have:

· 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

Qualifications

What You Bring to Our Team

Level I

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)

Level II

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 toolsLeads 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)

UPON HIRE, must have:

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

Physical and Mental Requirements:

Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
Ability to maintain regular, punctual attendance.
Ability to sit for 6-8 hours.
Constant use of computer keyboard and mouse; repetitive use of both hands.
Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Benefits

The Highlights:

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Unlimited PTO—rest and recharge time is non-negotiable
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets

Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $95,000 - $105,000. depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Personify Health

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