Utilization Management Manager (Medical)

TL;DR

Utilization Management Manager (Medical): Managing the performance of the UM nurse team supporting PACE programs with an accent on SLA achievement, clinical decision support criteria, and quality assurance. Focus on driving inter-rater reliability, handling complex provider disputes, and optimizing care transitions for vulnerable seniors.

Location: Must be based in the United States

Salary: $115,000

Company

hirify.global provides an end-to-end ecosystem specifically built to help Programs of All-Inclusive Care for the Elderly (PACE) deliver exceptional care and stay compliant.

What you will do

• Own end-to-end delivery of the UM program, ensuring all SLAs for turnaround times, decision timeliness, and quality benchmarks are met.
• Manage, coach, and recruit the UM nurse team, conducting regular performance reviews and building competency-based training programs.
• Ensure consistent application of PACE authorization policies and clinical decision support criteria (e.g., MCG) across all cases.
• Design and lead quality assurance (QA) and inter-rater reliability activities to identify and address decision-making variance.
• Handle a defined caseload of complex UM reviews and lead the provider dispute process for escalated cases.
• Partner with Medical Directors and provider networks to align on authorization decisions and care strategies.

Requirements

• Current, active Registered Nurse (RN) license in good standing.
• 7+ years of utilization management experience, including risk-based, integrated care models.
• 5+ years of direct people-management experience leading clinical reviewers or UM nurses.
• Demonstrated experience with clinical decision support criteria such as MCG or InterQual.
• Strong data literacy and ability to use dashboards and analytics to diagnose performance gaps.
• Must be based in the USA; this position is not eligible for sponsorship.

Nice to have

• Certification in case management or utilization review (e.g., CCM, ACM, CPHM).
• Experience with rapid-cycle improvement methodologies such as PDSA, Lean, or Six Sigma.

Culture & Benefits

• Fully remote work arrangement within the United States.
• Culture of accountability, collaboration, and psychological safety.
• Environment focused on continuous improvement and professional growth.
• Opportunity to impact care for socially vulnerable and clinically complex seniors.