Manager of Utilization Management and Complex Care Management

Job Summary

This role provides day-to-day operational leadership for the Utilization Management, Transitional Care, and Care Management teams, supports the execution of processes designed to improve health outcomes, reduces healthcare utilization costs, and facilitate effective care transitions for complex populations. The Manager collaborates closely with the Medical Center leadership, Market Leadership and other stakeholders to ensure a seamless continuum of care across inpatient, ambulatory, and community-based settings.

Acting as a key liaison between staff Medical Center, Market Leadership, and the supporting care teams the Manager facilitates communication and promotes efficient team operations. Additionally, the Manager oversees/conducts performance evaluations, handles disciplinary actions, and works with the leadership team to uphold high service standards. Success in role is measured by meeting and/or exceeding KPI targets around Admissions/1000, Readmissions/1000, Average length of stay and ED Utilization, employee engagement and effective execution of clinical programs.

Duties and Responsibilities

• Team Leadership and Oversight

• Lead and manage a diverse care management team, including registered nurses, social workers, non-licensed personnel (if part of the assigned staff)

• Oversee staff development/ performance management and ensure adherence to TCM/UM and Care management standards, including person-centered care planning, SMART goals, and documentation protocols aligned with NCQA, regulatory, and health plan standards.

• Ensure Care plan, assessment and member engagement audits are being completed

• Conduct performance management activities, including case audits, one-on-one coaching, and training, ensuring compliance with quality and accreditation standards.

• Manage caseloads to ensure follow-up, timely documentation, and compliance with organizational and health plan requirements.

• Assist with team member prioritization and focus on high impact members

• Communicate meetings and trainings content to staff and ensure they incorporate into their work, Ensure compliance with mandatory training.

• Foster a culture of collaboration, cooperation and accountability individually as well as a team

• Reviews KPIs on a regular basis with the care/utilization management teams to and initiates a root cause analysis then corrective action if metrics are not on track

• Collaboration and Interdisciplinary Care

• Coordinate with community-based organizations, primary care providers, and specialists to address members’ chronic care needs, facilitate transitions of care, and support member retention.

• Partner with inpatient facility case management departments for collaborative discharge planning and continuity of care.

• Facilitate /Chair effective and efficient interdisciplinary care team (ICT) meetings/Huddles, documenting actions to be taken with a clear owner and timeframe, ensuring follow-up on action items to enhance member outcomes.

• Partner with medical director to ensure effective member outcomes are being achieved

• Operational and Performance Improvement

• Use data and reporting to monitor team performance and drive improvements in utilization, health outcomes, quality metrics, and member satisfaction.

• Proactively identify low-performing staff or processes, implementing improvement plans or process optimizations as needed.

• Apply evidence-based guidelines (e.g., MCG, InterQual, CM Playbook) to ensure appropriate levels of care, reduce readmissions, and improve transitions.

• Conducts regular UM and CM staff performance audits – chart reviews, metrics/score card reviews and takes action when metrics are not meeting targets

• Member Engagement and Case Management Expertise

• Serve as a subject matter expert (SME) on care management, chronic conditions, and organizational information systems, leading training and promoting best practices in member care as well as Utilization Management/Care transitions.

• Address complex needs of populations with medical, behavioral, and socioeconomic barriers through data-driven interventions and therapeutic approaches such as motivational interviewing and trauma-informed care.

• Stakeholder Relationship Management

• Develop and maintain relationships with payors, facility leadership, and community organizations to support integrated member care and overcome barriers such as housing, food security, and financial instability.

• Actively participate in both internal and external meetings, representing the organization’s mission, vision, and values.

• Onboarding, Hiring, and Staff Engagement

• Conduct interviews, hiring, onboarding, and training for new team members, ensuring alignment with organizational goals.

• Ensures appropriate coaching and mentoring activities for new hires are in place and does periodic 1:1s with new staff to evaluate assimilation.

• Conducts skip level meetings periodically (if there are supervisors reporting to this position)

• Lead effective and efficient team meetings, engage in team-building activities, and maintain staff morale and productivity through virtual and in-person methods.

• Responsible for employee engagement scores and staff turnover metrics.

• Additional Responsibilities

• Maintain the privacy and security of member information as per organizational and legal standards.

• Adapt to dynamic environments, managing competing priorities and supporting business needs through flexible, innovative solutions.

• Meet deadlines and uphold organizational core values in daily operations.

Minimum QualificationsLicense, Education and Certification:

• Minimum License: Current, active, and unrestricted license in a health or human services discipline that, within its scope of practice, allows you to conduct an assessment independently (e.g. RN, LCSW, LMSW- prefer RN or APP).

• Minimum Certifications: Certified Care Manager is a highly preferred requirement

• BLS/CPR required.

• Minimum Education: Associate’s degree in health or human services discipline required.

• Bachelor’s or Master’s degree in nursing, business, Healthcare Administration/Public Health, Finance, or a related field a plus.

• Advanced clinical practice (e.g. CNS/APN, LCSW/LISW, PsyD/PhD) a plus

• Other Certifications Considered: CPHQ or similar certifications a plus.

Experience

• 5-7 years’ experience, with 3-5 years in leadership, ideally in Value-Based Care, Utilization Management, or Complex Care Management, preferably both UM and CM

• Experience with complex populations (e.g., Medicaid, Medicare, dual-eligibles), including medically complex (aged, blind, disabled) and socially vulnerable individuals.

• Proficiency with evidence-based care transition strategies, including discharge planning, ambulatory care and community-based care coordination.

• Technical and Analytical Skills

• Advanced computer skills in Microsoft Office Suite (Word, Excel, Teams) Adobe PDF, Care Management and electronic health record (EHR) systems.

• Strong data analysis and reporting abilities to drive performance improvements and process optimization.

• Familiarity with AI uses and some experience using to facilitate work

• Interpersonal and Communication Skills

• Excellent verbal and written communication skills for interactions with members, families, stakeholders, and interdisciplinary teams.

• Proven ability to foster team morale, handle change, and work independently while making sound clinical judgments.

Working conditions

This job operates in the community and within a professional office environment. This role requires reliable transportation to commute back and forth between inpatient facilities and office; and routinely uses general office equipment. This role requires a dedicated, quiet workspace with the ability to adhere to HIPAA and other privacy policies. A reliable and high-speed Wi-Fi connection or home internet is required to perform the essential functions of this role. Use of personal vehicles is required for daily community travel. Ability to travel regionally and nationally up to 80%

Physical requirements

• Ability to operate computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

• Valid driver’s license with automobile insurance, with ability to travel up to 80% within the local area.

• Reliable transportation.

• This role is expected to travel between the center as well as local facilities (ie – hospitals, SNFs, etc).

Direct reports

May include any combination or one:

• Transitional Care Managers

• Complex Care Managers

• UM/CM Supervisors