Director, Utilization Management

    March 14, 2022
    Los Angeles, California
    Job Type


    We are seeking candidates for a Director, Utilization Management  role with Prime Health Plan located in Los Angeles CA

    Salary: USD $127,000 – $165,000 / yr

    Job Summary

    The Director, Utilization Management (UM) is directly responsible for the planning, organizational direction, staffing and development of L.A. Care's Utilization Management function(s). The main functions includes but is not limited to in patient, and outpatient utilization review, care transitions, Member and Provider Outreach. As the health plan, the Director of UM also needs to support our contracted delegates when needed.  Main responsibility includes: regulatory compliance, accreditation compliance, assistance with oversight of Plan Partners and Delegated Provider Groups related operations, oversight vendor's related delegated functions, operations for direct lines of business and/or management services agreement functions, and interfacing with external agencies including other Local Initiatives, Plan Partners and external organizations. The Director, Utilization Management is further responsible to lead and direct the department to ensure all functions are operating in accordance with the organization's mission, values and strategic goals and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. This position is remote, however, you will be required to attend staff meeting at least twice a month if office.


    Education Required

    Bachelor's Degree in Nursing

    Education Preferred

    Master's Degree in Nursing



    At least 7 years experience in implementing and managing of Medicaid and Medicare program requirements with 5-7 years of supervisory/management experience in a health care/health plan environment.

    Experience in obtaining and sustaining National Committee for Quality Assurance (NCQA) accreditation.



    Experience in Medicare-SNP programs.


    Skills  Required:

    Excellent verbal and written communication skills.

    Excellent problem solving, planning, and organizational skills.

    Persuasion Skills: Ability to work collaboratively internally and externally to achieve results is critical.

    Licenses/Certifications Required

    Registered Nurse (RN) - Active, current, and unrestricted California License

    Licenses/Certifications Preferred

    Required Training

    Registered Nurse (RN)


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