Manager, Clinical Utilization Management

Location: Village of Garden City

Manager, Clinical Utilization Management (Garden City, NY)

Health Care Partners, IPA and Health Care Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, Health Care Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products.

Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team?

Position Summary: The Manager, Utilization Management (UM) is responsible for providing strategic leadership and operational oversight for both inpatient and outpatient utilization management clinical teams, including prior authorization, concurrent review, and care coordination functions. This role is accountable for driving clinical quality outcomes, reducing medical loss ratio (MLR), decreasing avoidable admissions and readmissions, and aligning utilization management activities with organizational quality metrics and regulatory requirements.

The Manager ensures appropriate utilization of healthcare services across the continuum of care, with a strong focus on proactive discharge planning, high‑risk population management, and interdisciplinary collaboration. This position partners closely with Case Management, High Risk Care Management, Pharmacy, Medical Directors, and Clinical Operations to develop clinical solutions that optimize patient outcomes while maintaining cost‑effective care delivery.

This role also participates in a rotational management on‑call program, providing leadership support during after‑hours and weekend periods as needed.

Essential Position Functions/Responsibilities:

• Provide strategic and operational leadership for inpatient and outpatient utilization management teams
• Oversee Prior Authorization, Concurrent Review, and Inpatient Utilization functions
• Manage clinical staff across UM teams
• Establish departmental goals aligned with organizational strategic objectives
• Promote a culture of accountability, collaboration, and continuous improvement
• Ensure staff adherence to policies, procedures, and regulatory requirements
• Conduct performance evaluations, coaching, and professional development planning
• Maintain appropriate staffing models to support operational efficiency and service levels
• Monitor and analyze utilization data to identify trends, opportunities, and performance gaps
• Drive initiatives to reduce admissions, readmissions, and unnecessary utilization
• Implement strategies to reduce medical loss ratio (MLR) while maintaining quality outcomes
• Ensure alignment with clinical quality metrics and population health initiatives
• Oversee appropriate application of clinical criteria including MCG and payer guidelines
• Audit utilization decisions for clinical appropriateness and compliance
• Evaluate and improve workflows to enhance operational efficiency
• Monitor turnaround time, productivity, and key performance indicators
• Lead development and monitoring of utilization management programs
• Partner with Director of Pharmacy to develop clinical solutions and optimize medication…