Manager, Utilization Management

CareSource

. Oversee all utilization management activities to ensure consistency of services and achievement of utilization targets .

Posted 11/10/2026full-timeRemote • United StatesMid-LevelSenior💰 $83,000 - $132,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management, case management, and quality improvement within the healthcare sector, ensuring compliance with state regulations and organizational policies. Proficient in data analysis, reporting, and developing departmental policies to enhance service delivery and operational efficiency.

Highest-signal resume keywords

Utilization ManagementCase ManagementQuality ImprovementData AnalysisRegistered Nurse (RN) Licensure

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization Management StandardsClinical ReviewWorkflow OptimizationData TrendingTechnical Writing

Soft Skills

Leadership SkillsNegotiation SkillsTraining SkillsStrategic Management SkillsTeam Collaboration

Tools & Technologies

ExcelWordPowerPoint

Certifications & Qualifications

Registered Nurse (RN) Licensure

Industry Keywords

Managed CareNCQA RegulationsURAC RegulationsHealthcare ComplianceContinuous Quality Improvement (CQI)

About the role

Key responsibilities & impact

Oversee all utilization management activities to ensure consistency of services and achievement of utilization targets
Coordinate and manage the pre-determination process for medical and dental services
Ensure consistent application of authorization criteria and appropriate clinical review of adverse decisions
Develop integrated service delivery and oversee utilization management data and processes
Manage benefits aligned with state regulations, NCQA and/or URAC regulations, and CareSource policies
Review and revise workflows to maximize efficiencies
Monitor productivity and utilization trends
Oversee CQI activities, audits, and staff feedback
Report utilization management regulatory requirements and maintain compliance
Maintain utilization management reporting and trend data
Analyze under- and over-utilization impacts on member quality of care and outcomes
Develop, maintain, and update departmental policies and procedures
Audit predetermination requests, documentation, and interrater reliability
Liaise with other departments on research and intervention
Perform other job-related instructions as requested

Requirements

What you’ll need

Associate’s Degree in Nursing is required; Bachelor of Science in Nursing (BSN) preferred
Minimum of five (5) years of clinical experience required
Minimum of five (5) years of experience in case management, utilization management, and/or quality improvement required
Two years of utilization management experience preferred
Managed care experience preferred
Beginning Excel, Word and PowerPoint experience
Experience in data analysis and trending
Knowledge of utilization management standards and practices
Management and prior supervisory skills
Ability to work independently and within a team environment
Familiarity with the health care field
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Technical writing skills
Leadership experience and skills
Current, unrestricted licensure in state of practice as a Registered Nurse (RN) is required

Benefits

Comp & perks

Bonus tied to company and individual performance
Substantial and comprehensive total rewards package
Employee total well-being support