RN Manager of Utilization Management

As the RN Manager of Utilization Management, you will lead healthcare program operations and a team of clinical professionals supporting population health, utilization management, quality improvement, and care management activities. You will oversee contract performance, staff development, operational excellence, and client relationships while ensuring compliance with contractual, regulatory, and accreditation requirements. You will use your knowledge of medical policy, medical coding, ICD-10 and CMS requirements to support evidence-based coverage determinations and effective utilization management practices. This role is ideal for an experienced nurse leader who enjoys building high-performing teams, improving healthcare outcomes, and partnering with clients to achieve program goals.

What You'll Do:

Manages the day-to-day operations of multiple and diverse health management lines of service and/or contracts/programs
Leads team in creation of a strategic plan, implementation of plan, evaluation and ongoing management to ensure contract deliverables/program requirements and evaluation measures/metrics are met and/or exceeded within assigned funding/budget
When deliverables/requirements are at risk, facilitates analyses and initiatives action plan
Develops and maintains relationships with team stakeholders
Provides technical assistance, including issue research and resolution
Develops and implements process improvement methods for an organization whose philosophy is continual improvement
Depending on the scope of assigned area, may facilitate national programs/projects
Ensures the operations are completed in a timely, satisfactory, compliant manner within assigned funding/budget
Participates in sales, business development and proposal work activities including development of concept papers, contributing content or review of proposals as a subject matter expert
Has financial accountability for monitoring budgets and financials for assigned contracts
Coaches, guides and directs team members to achieve individual, team and organizational objectives
Fulfills the Telligen Management Philosophy that "Managers coach, engage, and support our people to achieve results"
Provides resources and support as needed to meet the departmental and Company goals and specific contract/program requirements
Represents the company and presents at meetings and/or conferences
Works externally with providers or clients as assigned
Makes recommendations for improvements and/or efficiencies to management
Initiates opportunities to expand knowledge, skill development, and certifications which enhance quality improvement activities and the achievement of contract deliverables
Stays abreast of industry trends and changes. Performs miscellaneous duties as assigned

Required Skills and Experience:

• Four-year degree in nursing with a current Iowa RN license or the ability to become licensed in the state of Iowa
• 5 years of experience in medical coding and utilization management including: claims, billing, prior authorization, and appeals
• 3-5 years of experience managing projects and professional staff; demonstrated experience working in a fast paced and deadline driven environment
• Experience with URAC and NCQA health plan accreditation specific to utilization management
• Experience with claims post pay medical necessity reviews
• Experience with reviewing medical codes for coverage determination including establishment of medical policy and demonstrated knowledge of how utilization management and medical policy work together to support evidence-based coverage determinations, and code update implementations including ICD-10 and CMS
• Knowledge of the following Leadership Principles
• Strategic planning, implementation and evaluation
• Leading Change
• Leading people: coaching, guiding and training
• Conflict management: difficult conversations
• Knowledge of financial principals including budgeting
• Building and maintaining stakeholder relationships
• Positions working on specific contracts may require U.S. Citizenship
• This role offers a flexible hybrid schedule, combining the convenience of remote work with two days per week onsite for meaningful collaboration, team connection, and partnership.

Preferred Skills and Experience:

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 process tools
Basic statistics, data collection techniques, data analysis and graphic representation of data
Familiarity with Iowa HHS Administrative Rules and Administrative Rule Waiver
Certified Professional in coding and billing
Facilitation including Group Process Facilitation
QI Process: Focus-Analyze-Develop-Execute/ Plan-Do-Study-Act
Experience dealing with sensitive information