Utilization Management Supervisor

Salary Range: $70,298.00 To $87,872.50 Annually

The Supervisor of Utilization Management (UM) provides leadership, clinical oversight, and operational direction for the UM team, ensuring timely, consistent, appropriate, and compliant utilization management practices. This position is responsible for supervising and developing UM Clinical Analysts; overseeing the quality, consistency, timeliness, and appropriateness of utilization management activities; and ensuring compliance with applicable organizational, regulatory, contractual, and accreditation requirements. The Supervisor of UM applies clinical expertise, utilization management standards, business rules, and regulatory requirements to support appropriate, effective, and efficient use of services and resources across the OCHN provider network.

The Supervisor of UM oversees prospective, concurrent, and retrospective utilization management activities; monitors utilization and performance data; leads audit and quality improvement activities; and supports the development, implementation, and maintenance of UM policies, procedures, protocols, and processes. The position works collaboratively with providers, community partners, and internal departments to address complex and high-risk cases, promote effective care coordination, identify opportunities for improvement, and ensure services are delivered in accordance with the individual's needs and goals.

This position serves as a key resource and subject-matter expert for UM practices, providing consultation, education, coaching, and training to UM staff and the provider network. This position also contributes to organizational initiatives, interdisciplinary work groups, accreditation activities, and continuous quality improvement.

• Provide administrative and supervisory oversight for all functions performed by the Utilization Management (UM) Clinical Analysts and ensure the team operates in accordance with organizational standards, regulatory requirements, and established policies and procedures.
• Provide leadership, direction, coaching, teaching, facilitation, coordination, problem-solving, and conflict resolution to UM staff.
• Monitors and evaluates the quality, consistency, and timeliness of authorization decisions, and other utilization management reviews conducted by the team.
• Demonstrates an applied commitment to the values as well as knowledge and skills in person served-oriented practices as well as innovations in support, service, treatment, and care practices.
• Assures adequate supervision/evaluation and performance management processes for all assigned staff members and delegate responsibilities to ensure adherence to clinical criteria, business rules, regulatory requirements, and organization policies.
• Ensures effective orientation, onboarding, and training for new employees and supports ongoing competency development and inter-rater reliability activities for UM staff.
• Manage reports and data for audits and complete audit preparation, oversight to auditing processes, and manage audit process improvements.
• Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
• Conducts and/or oversees prospective, concurrent, and retrospective utilization reviews to evaluate the clinical appropriateness, medical necessity, and effective use of services.
• Conducts prospective reviews for service authorizations as identified by OCHN and performs concurrent clinical case reviews as requested.
• Conducts retrospective reviews of service provision to determine whether services were delivered in the appropriate amount, scope, and duration to reasonably achieve the goals identified in the Individualized…