Manager, Utilization Management

Cambia Health Solutions

. Plan, direct, and manage utilization management professional and support staff .

Posted 10/9/2026full-timeUnited StatesSeniorLead💰 $95,000 - $172,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management and clinical case management, with a strong focus on policy development, team leadership, and regulatory compliance. Proven ability to manage financial targets and oversee departmental operations while maintaining clinical competency and knowledge of industry trends.

Highest-signal resume keywords

Utilization ManagementClinical Case ManagementLeadership ExperienceRegistered Nurse (RN) LicensureInsurance Industry Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Care ExperienceProject ManagementStatistical AnalysisBudgetingPolicy DevelopmentProcess ImprovementPerformance ManagementResource AllocationProgram DevelopmentQuality Assurance

Soft Skills

Effective CommunicationTeam LeadershipCoachingProblem SolvingMeeting Facilitation

Tools & Technologies

AI Tools and TechnologiesHealth Insurance Technology

Certifications & Qualifications

Registered Nurse (RN) Licensure

Industry Keywords

Utilization Management ProgramsInsurance Industry TrendsRegulatory ComplianceClinical CompetencyPayment Review Management

About the role

Key responsibilities & impact

Plan, direct, and manage utilization management professional and support staff
Oversee staff directly or through subordinate supervisors
Lead utilization management programs across all Cambia plans, including prospective, concurrent, retrospective, post-service claims review, and bill audit procedures
Represent the department with management, vendor partners, clients, providers, government officials, and outside consultants
Develop and execute utilization and/or payment review management policies, procedures, and standards
Oversee policy updates and process improvements to ensure quality and service excellence
Manage staff performance reviews, development, hiring, coaching, counseling, retention, and talent management
Communicate organizational objectives and team goals
Monitor results and metrics to ensure deliverables and regulatory compliance
Collaborate across departments to resolve issues
Manage financial targets, department budget, expenditures, workforce allocation, resources, and project plans
Establish long-term departmental goals and adapt operational plans
Promote utilization management and/or payment review programs
Develop resource materials and provide program education and communication to employees, providers, and community stakeholders
Maintain clinical competency and current knowledge of medical practices, procedures, and industry trends
Develop and present educational updates
Oversee department program development and implementation, quality, and outcomes
Supervise 10–15 FTEs

Requirements

What you’ll need

Bachelor's degree in nursing or related field; master's preferred
5 years of clinical care experience
5 years of leadership experience
7 years of insurance industry experience or equivalent combination of education and experience
Current unrestricted Registered Nurse (RN) licensure in a state or territory of the United States
Ability to identify issues, opportunities, and effective solutions
Competency in resource and project management, including budgeting, work organization, staff leadership, success measures, and deliverables
Ability to develop and lead teams, including hiring, goal setting, coaching, and development
Effective verbal and written communication, meeting facilitation, and presentation skills
Familiarity with health insurance industry trends and technology
Competency in clinical case management and utilization management practices
Experience with statistical analysis and its application in utilization management programs
Experience with AI tools and technologies highly desired
Wired internet connection required for work-from-home option; minimum 5Mb upload and 10Mb download speeds
Access to a personal mobile device required for MFA
Successful background check required

Benefits

Comp & perks

Competitive salary
Bonus opportunities
Market-leading 401(k) with a significant company match
Potential discretionary 401(k) contribution based on company performance, with no vesting period
Medical, dental and vision coverage for employees and eligible family members, including mental health benefits
Annual employer contribution to a health savings account
Generous paid time off varying by role and tenure
10 company-paid holidays
Up to 12 weeks of paid parental time off after 12 months of continuous service
Award-winning wellness programs that reward participation
Employee Assistance Fund
Commute and parking benefits
Flexible work from home options for most roles
Employee resource groups
Professional growth and career development opportunities
Cambia-supported community outreach programs