Utilization Management Manager

Job description

About IntusCare: IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. We empower teams to take control of their operations and improve outcomes for dual-eligible seniors- some of the most socially vulnerable and clinically complex individuals in the US healthcare system. Position Overview: The Utilization Management (UM) Manager is fully accountable for the performance of the UM nurse team supporting a Program of All-Inclusive Care for the Elderly (PACE). This role owns end-to-end delivery of the UM program, including meeting all service-level agreements (SLAs), ensuring consistent application of policies, procedures, and clinical decision support criteria, and driving continuous improvement across the UM function. The UM Manager spends approximately 25% of their time working directly on UM cases and provider disputes—maintaining clinical currency, modeling best practices, and handling escalated or complex reviews—and the remaining 75% managing team performance, service quality, staffing, coaching, and cross-functional coordination. The role partners closely with the IntusCare Utilization Management clients, the IntusCare Director of Clinical Operations and the Contracted Physician to assure high quality service and customer service. KEY RESPONSIBILITIES TEAM LEADERSHIP & PERFORMANCE MANAGEMENT (APPROXIMATELY 75% OF TIME) • Hold full accountability for UM team performance, including meeting or exceeding all program SLAs (turnaround times, decision timeliness, dispute resolution timelines, documentation completeness, and quality benchmarks). • Establish, monitor, and report on individual and team performance metrics; conduct regular one-on-ones, performance reviews, and coaching sessions to drive accountability and professional growth. • Ensure consistent application of PACE service authorization policies, standard operating procedures, and clinical decision support criteria (e.g., MCG) across every reviewer and every case. • Design and lead ongoing quality assurance (QA) and inter-rater reliability activities; identify variance in decision-making, address it through targeted coaching or process changes, and document outcomes. • Manage staffing, scheduling, workload distribution, and case assignment to ensure sustained SLA performance during volume fluctuations, coverage gaps, and PTO. Perform case reviews as needed during staff PTO to assure timely case completion and accuracy. • Recruit, onboard, and develop UM nurses; build competency-based training programs and structured ramp plans for new hires. • Foster a culture of accountability, collaboration, psychological safety, and continuous improvement. • Maintain and update UM policies, procedures, workflows, and job aids; ensure changes are communicated, trained on, and audited for adoption. • Partner with the contracted IntusCare Contracted Physician to define escalation pathways and ensure clinical decision-making support is available when needed. • Use data analytics to monitor care patterns, cost drivers, length-of-stay trends, denial and overturn rates, and utilization efficiency; translate findings into targeted improvement initiatives. • Lead or sponsor rapid-cycle performance improvement initiatives across UM functions. • Prepare and present program performance reporting to internal leadership and PACE client stakeholders. DIRECT UM CASE & DISPUTE WORK (APPROXIMATELY 25% OF TIME) • Personally handle a defined caseload of UM reviews and provider disputes to remain clinically current, model expected practice, and manage escalations. This includes: ◦ Initial and Concurrent review of hospital admissions (observation and inpatient) with the PACE primary care and IDT teams, driving efficient and timely transitions of care, and retrospective review of inpatient admissions under 48 hours and claims submitted inconsistent with the service authorization. ◦ Concurrent review of subacute and SNF admissions with the IDT, driving efficient and timely discharge plans and transitions of care. • Lead the provider dispute process on complex or escalated cases, including: ◦ Comprehensive review of provider network disputes. ◦ Collaboration with the PACE program's finance and claims adjudication team to coordinate clinical review supporting disputed claims. ◦ Collaboration with the IntusCare Contracted Physician to review and respond to disputes, ensuring written determinations consistent with IntusCare policies. STAKEHOLDER ENGAGEMENT & COMMUNICATION • Partner with PACE organizations, Medical Directors, IDTs, and provider networks to strengthen communication and ensure alignment on authorization decisions and care strategies. • Facilitate education, training, and cross-functional collaboration to improve UM consistency, documentation accuracy, and compliance with IntusCare standards. • Serve as one of the primary points of contact and accountable owner for IntusCare UM program performance in client-facing meetings. ACCOUNTABILITY & SUCCESS MEASURES The UM Manager will be evaluated against outcomes including, but not limited to: • Achievement of all UM program SLAs, including authorization decision turnaround times and dispute resolution timelines. • Inter-rater reliability scores and QA audit results demonstrating consistent application of policies, procedures, and clinical decision support criteria. • Team engagement, retention, and time-to-productivity for new hires. • Timeliness, accuracy, and defensibility of dispute determinations. REQUIRED QUALIFICATIONS • Current, active Registered Nurse (RN) license in good standing. • 7+ years of utilization management experience, including experience in risk-based, integrated care models. • 5+ years of direct people-management experience leading a team of clinical reviewers or UM nurses, with clear accountability for team-level SLAs and performance outcomes. • Demonstrated experience owning and improving inter-rater reliability, QA programs, and consistent application of clinical decision support criteria (e.g., MCG, InterQual). • Strong data literacy—able to use dashboards and analytics to diagnose performance gaps and drive targeted interventions. • Proven ability to manage competing priorities in a fast-paced, performance-driven environment. • Excellent written and verbal communication skills, including comfort presenting to executive and client audiences. PREFERRED QUALIFICATIONS • Experience implementing or scaling UM operations across multiple client organizations or sites. • Certification in case management or utilization review (e.g., CCM, ACM, CPHM). • Experience with rapid-cycle improvement methodologies (PDSA, Lean, Six Sigma). CORE COMPETENCIES • Ownership and accountability for team outcomes • Coaching and performance management • Clinical accuracy and attention to detail • Analytical and data-driven decision-making • Process improvement mindset • Collaboration and relationship-building across clinical and non-clinical audiences • Strong written communication, particularly for defensible clinical determinations COMPENSATION: The base salary for this role is $115,000. Final compensation will be determined based on experience, skills, and organizational needs. Work location: This is a fully remote role based in the United States. Sponsorship: This position is not eligible for sponsorship.