Program Manager, Utilization Management

Description

Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than 1,500 senior living community partners across 34 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the healthcare system. Our mission: To radically improve the health, happiness and dignity of senior living residents.

Job Summary:

The Program Manager – Utilization Management will be accountable for the management, implementation, communication, and execution of the program and/or projects for utilization management.  Additionally, this role will serve as a key liaison for the Utilization Management department, fostering effective communication and collaboration with other departments to ensure alignment of goals, processes, and regulatory standards.

In this key position, you will be responsible for the planning and execution of programs/projects of the Clinical Programs department. This position reports directly to the Vice President of Clinical Programs and is an important position in the achievement of strategic and operational goals.

This position involves developing, coordinating, tracking, implementing, training, and evaluating projects and programs to support accurate and efficient medical review, case management, and decision-making aligned with company policies and regulatory requirements.

Essential Duties and Responsibilities:

• Support Clinical Programs team with regards to implementation and communication (internal and external) of operational management processes.
• Collaborate with leadership to establish metrics for quality assurance, ensuring alignment with organizational goals.  Analyze trends, costs, and quality data and communicate recommendations and opportunities to Clinical Programs leadership.   
• Develop processes for the creation, tracking, and reporting of all operational management changes within the Clinical Programs Department.
• Oversee and ensure accurate configuration and appropriate administration for alignment between contracts, regulatory requirements, policies and procedures.
• Monitor and assess the effectiveness of programs, gathering feedback to identify areas for improvement.

• Act as a bridge between the UM department and other teams, facilitating communication, addressing cross-departmental questions and education, and ensuring consistent understanding of clinical programs processes and operations.
• Represent the Clinical Programs department in organizational meetings to provide insights into program updates, regulatory changes, and emerging needs and opportunities

• Work collaboratively with team on development, evaluation and updating UM protocols and annual training including IRR, best practices, and regulatory standards to ensure compliance and quality in medical review processes.
• Provide education and support for UM teams (Non-Clinical, Clinical, and Physicians) ensuring they understand and apply UM guidelines, clinical criteria, and documentation standards in their review processes.

• Assist and participate with the clinical team to update educational content to reflect on the latest clinical practices, health regulations, and insurance policies to keep staff and Physicians informed.

• Participate and/or lead sessions on internal and external audit preparation and all other regulatory and accreditation standards.
• Other duties as assigned

Education and Experience:

• Bachelor’s degree required. Master’s degree preferred. An additional four (4) years of experience will be considered in lieu of degree.
• Five (5) years of experience in health plan managed care operations required; multi-dimension project management experience preferred.
• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active, unrestricted license preferred.
• Knowledge of clinical care management processes, member benefit structures and applications, and claims processing.
• Knowledge of utilization management, claims systems, clinical platforms and/or CRM applications.
• Prior experience with MCG and the MCG Modification tool functionality.
• Ability to define problems, analyze data/information and critically think through scenarios.
• Knowledge and experience in the development of clinical processes and SOPs.
• Knowledge of ICD-10, CPT and HCPCS coding.    
• Knowledge of program implementation with project management approach.
• Excellent verbal, written and interpersonal communications skills required with emphasis on diplomacy, negotiation, persuasiveness and interaction with multiple levels of management.
• Ability to work independently and lead or participate in multi-disciplinary project teams.
• Excellent time management and organizational skills.

Curana Health is dedicated to the principles of Equal Employment Opportunity. We affirm, in policy and practice, our commitment to diversity. We do not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable or state law, genetic information, or any other characteristic protected by applicable federal, state and local laws and ordinances.

The EEO policy applies to all personnel matters as outlined in our company policy including recruitment, hiring, transfers, and general treatment during employment.

*The company is unable to provide sponsorship for a visa at this time (H1B or otherwise).

Qualifications