Manager - Utilization Management; RN

The Manager of Utilization Management (UM) is responsible for the operational leadership, compliance oversight, and performance management of Utilization Management programs across assigned contracts and lines of business. This role ensures UM activities are delivered in accordance with contractual requirements, accreditation standards (e.g., URAC), regulatory obligations, and evidence-based medical necessity criteria.

The Manager oversees UM staff and workflows related to prior authorization, concurrent review, retrospective review, medical necessity determinations, peer review processes, and denial communications. The position is accountable for timeliness, quality, compliance, staff competency, and continuous improvement of UM operations while maintaining budgetary and performance expectations.

• UM Operations & Program Management
• Manage the day-to-day operations of Utilization Management programs across multiple contracts and populations.
• Lead planning, implementation, evaluation, and ongoing management of UM workflows to ensure compliance with regulatory, accreditation, and contractual requirements.
• Monitor key UM performance indicators including timeliness, determination accuracy, appeal overturn rates, and documentation quality. When risks or gaps are identified, leads root cause analysis and corrective action planning.

• Compliance, Accreditation & Process Improvement
• Ensure UM operations remain compliant with applicable federal and state regulations, client requirements, and accreditation standards (e.g., URAC).
• Partner with Quality and Compliance teams to support audits, corrective action plans (CAPs), policies, procedures, and readiness activities.
• Lead continuous improvement initiatives focused on clinical consistency, medical necessity application, letter accuracy, peer review processes, and regulatory adherence.

• Financial & Contract Accountability
• Maintain financial accountability for assigned UM contracts, including staffing models, productivity expectations, and budget adherence.
• Monitor operational performance against contractual service level agreements (SLAs) and utilization benchmarks.
• Participate in proposal development, pricing inputs, and operational feasibility discussions as a UM subject matter expert.

• Staff Leadership & Development
• Coach, guide, and direct UM staff to achieve individual, team, and organizational objectives.
• Ensure appropriate training, competency validation, and ongoing education for UM nurses, physician reviewers, and support staff.
• Foster a culture of accountability, clinical integrity, and continuous improvement consistent with Telligen’s Management Philosophy that managers coach, engage, and support people to achieve results.

• Stakeholder Engagement & Representation
• Represent Telligen in meetings with clients, providers, regulators, and internal stakeholders related to UM operations.
• Collaborate with Medical Directors, Compliance, Quality, and Operations leadership to resolve issues and improve service delivery.
• May present UM outcomes, trends, and improvement initiatives to internal or external audiences.

• Industry Awareness & Special Projects
• Stay current on utilization management trends, regulatory updates, accreditation changes, and evolving medical management best practices.
• Perform other duties as assigned to support organizational goals.

• Four year degree in nursing, health care, business, public health or a related field and/or equivalent training and/or experience
• Graduate of an accredited nursing program (ACEN, CCNE), with an active, unrestricted RN license
• 5 years experience in healthcare environment including care management and/or health care quality improvement
• 3 – 5 years managing projects and/or a professional staff
• Demonstrated experience working in a fast paced and deadline driven environment
• Up to 20% local and overnight travel

• Knowledge of the following healthcare quality principles:
• Health care services, health care organizations and programs
• Information management processes, electronic health records and healthcare information technology
• Quality improvement concepts, principles and…