Manager, Utilization Management Claims Review

Job Summary

The Manager, Utilization Management Claims Review is responsible for overseeing the clinical and operational functions of the Claims Review team. This position provides leadership and strategic direction to ensure accurate clinical claim determinations, regulatory compliance, and adherence to established clinical policies.

The Manager drives payment integrity initiatives through effective oversight of pre-payment review, retrospective review, and Provider Dispute Review (PDR) processes while ensuring regulatory timeframes and quality standards are consistently met.

The Manager, Utilization Management Claims Review partners with internal departments and executive leadership to promote effective workflows, mitigate fraud, waste, and abuse (FWA), and support high-quality, cost-effective care delivery and organizational performance goals. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.

Participates and makes recommendations on the department's strategic planning and/or long-term decision-making.

Duties

Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Ensure quality standards are met by regularly reviewing claim files, clinical decisions, and Provider Dispute Review (PDR) determinations to confirm compliance with company policies, clinical guidelines, and regulatory requirements.

Identify trends or errors and implement improvements to increase accuracy and consistency. Establish team goals, monitor performance metrics, and ensure productivity and quality standards are met. Support recovery efforts and corrective action plans related to inappropriate billing or utilization patterns.

Oversee workflow and queue management to ensure claims and PDR requests are completed within required regulatory timeframes, including monitoring workload distribution.

Ensure adequate staffing resources and prevent backlogs or compliance risks.

Ensure clinical policies are applied correctly and consistently, including policies designed to prevent fraud, waste, and abuse (FWA). Potential FWA concerns are identified and escalated in partnership with Compliance and the Special Investigations Unit (SIU).

Duties Continued

Support audits, regulatory readiness, and cross-functional initiatives to maintain compliance with state, federal, and accreditation standards. Implement and monitor adherence to Utilization Management (UM) policies, procedures, and turnaround time requirements.

Work cross-functionally with leadership to ensure claims are aligned, and well-received by internal and external stakeholders.

Foster teamwork, accountability, and continuous improvement while ensuring departmental goals align with organizational priorities.

Manage complex projects, engaging and updating key stakeholders, developing timelines, leading others to complete deliverables on time and ensure implementation upon approval.

Responsible for reporting, budgeting, and policy implementation.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 6 years of experience in Clinical Nursing.

At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.

At least 4 years of leading staff, supervisor/management experience.

Experience in performing and creating clinical documentation.

Experience in regulatory compliance for a health plan.

Experience leading teams, projects, initiatives, or cross-functional groups.

Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Preferred: 

Experience with Provider Dispute Review (PDR) processes.

Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes.

Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.

Skills

Required:

Strong leadership, coaching, and team development skills.

Knowledge of medical necessity criteria, reimbursement principles, and managed care operation.

Knowledge of clinical policies.

Knowledge of CPT/HCPC Codes, and ICD-10.

Proficient in claims processing systems and electronic medical record platforms.

Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions.

Excellent verbal and written communication skills.

Ability to work independently with a high degree of initiative, organization, and self-direction.

Ability to work effectively with diverse teams in cross-functional work groups.

Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.

High organizational and time-management skills.

Familiarity with Centers for Medicare and Medicaid Services (CMS), Medi-Cal, or other regulatory frameworks.

Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

Must have a deep understanding of financial principles.

Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

Strong presentation skills.

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Preferred:

Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations.

Advanced knowledge of medical necessity criteria tools such as InterQual or MCG.

Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations.  

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information