Manager, Medical Utilization and Care Management

Back to jobsNewManager, Medical Utilization and Care ManagementCharlotte, North Carolina, United States; Denver, Colorado, United States; New York, New York, United StatesApplyAbout Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Judi Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.Position Responsibilities: Provide oversight for vendors conducting utilization management, care management, and clinical operations activities. Oversee vendor execution of utilization reviews, including prospective, concurrent, and retrospective reviews, to ensure medical necessity and appropriate level of care determinations. Monitor vendor review of medical records and treatment plans to support appropriate service utilization, avoid unnecessary or duplicate services, and optimize reimbursement outcomes. Partner with the Medical Director and vendor clinical leadership on complex cases, escalations, policy development, and clinical determinations. Provide oversight of vendor-managed prior authorization, peer-to-peer review, denial, appeal, and notification processes. Ensure vendors complete comprehensive biopsychosocial assessments and health risk assessments (HRAs) in accordance with program requirements. Oversee vendor-led care coordination across the continuum, including transitions of care and discharge planning. Provide oversight of vendor-administered chronic disease and complex case management programs. Monitor vendor documentation practices to support risk adjustment, compliance, and continuity of care. Review utilization trends and vendor performance data to identify quality improvement opportunities and ensure action plans are implemented. Ensure vendor compliance with applicable regulatory and accreditation standards, including URAC and NCQA requirements. Coordinate with vendor interdisciplinary teams, including nurses, social workers, and care coordinators, to promote aligned clinical operations and member outcomes. Promote vendor-delivered care coordination aligned with nursing practice principles and measurable quality, cost, and member experience outcomes. Required Qualifications: Active unrestricted RN license (BSN preferred) 5+ years of experience in utilization management, care management, or case management 2+ years leadership experience Knowledge of medical necessity reviews, care coordination models, and payer systems   Preferred Qualifications: Certification (CCM, CMGT-BC, HCQM). Experience with Commercial, Medicare and Medicaid population. Experience working with Medical Directors, Vendors, and Health Systems. Knowledge of URAC/NCQA standards.  New York, NY Salary Range$95,000 - $130,000 USDDenver, CO Salary Range$95,000 - $130,000 USDCharlotte, NC Salary Range$95,000 - $130,000 USDAll employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals. We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran...