Manager of Utilization Management and Complex Care Management

This role provides day-to-day operational leadership for the Utilization Management, Transitional Care, and Care Management teams, supports the execution of processes designed to improve health outcomes, reduces healthcare utilization costs, and facilitate effective care transitions for complex populations. The Manager collaborates closely with the Medical Center leadership, Market Leadership and other stakeholders to ensure a seamless continuum of care across inpatient, ambulatory, and community-based settings.

Acting as a key liaison between staff Medical Center, Market Leadership, and the supporting care teams the Manager facilitates communication and promotes efficient team operations. Additionally, the Manager oversees/conducts performance evaluations, handles disciplinary actions, and works with the leadership team to uphold high service standards. Success in role is measured by meeting and/or exceeding KPI targets around Admissions/1000, Readmissions/1000, Average length of stay and ED Utilization, employee engagement and effective execution of clinical programs.

• Team Leadership and Oversight
  • Lead and manage a diverse care management team, including registered nurses, social workers, non-licensed personnel (if part of the assigned staff)
  • Oversee staff development/ performance management and ensure adherence to TCM/UM and Care management standards, including person-centered care planning, SMART goals, and documentation protocols aligned with NCQA, regulatory, and health plan standards.
  • Ensure Care plan, assessment and member engagement audits are being completed
  • Conduct performance management activities, including case audits, one-on-one coaching, and training, ensuring compliance with quality and accreditation standards.
  • Manage caseloads to ensure follow-up, timely documentation, and compliance with organizational and health plan requirements.
  • Assist with team member prioritization and focus on high impact members
  • Communicate meetings and trainings content to staff and ensure they incorporate into their work, Ensure compliance with mandatory training.
  • Foster a culture of collaboration, cooperation and accountability individually as well as a team
  • Reviews KPIs on a regular basis with the care/utilization management teams to and initiates a root cause analysis then corrective action if metrics are not on track
• Collaboration and Interdisciplinary Care
  • Coordinate with community-based organizations, primary care providers, and specialists to address members’ chronic care needs, facilitate transitions of care, and support member retention.
  • Partner with inpatient facility case management departments for collaborative discharge planning and continuity of care.
  • Facilitate /Chair effective and efficient interdisciplinary care team (ICT) meetings/Huddles, documenting actions to be taken with a clear owner and timeframe, ensuring follow-up on action items to enhance member outcomes.
  • Partner with medical director to ensure effective member outcomes are being achieved
• Operational and Performance Improvement
  • Use data and reporting to monitor team performance and drive improvements in utilization, health outcomes, quality metrics, and member satisfaction.
  • Proactively identify low-performing staff or processes, implementing improvement plans or process optimizations as needed.
  • Apply evidence-based guidelines (e.g., MCG, Inter Qual, CM Playbook) to ensure appropriate levels of care, reduce readmissions, and improve transitions.
  • Conducts regular UM and CM staff performance audits – chart reviews, metrics/score card reviews and takes action when metrics are not meeting targets
• Member Engagement and Case Management Expertise
  • Serve as a subject matter expert (SME) on care…