Description:
We are seeking an experienced Registered Nurse to serve as an Interim Utilization Management Supervisor.
The ideal candidate will have leadership experience at the supervisor level or above within Utilization Management, along with direct case management experience. This individual will provide daily operational oversight, support clinical and nonclinical team members, manage departmental performance, and maintain continuity throughout the interim assignment.
What You Will Do:
- Provide daily leadership and operational oversight for the Utilization Management team.
- Supervise UM nurses, coordinators, case managers, and other assigned team members.
- Manage workflows involving prior authorization, concurrent review, retrospective review, referrals, and care coordination.
- Monitor productivity, turnaround times, documentation quality, service levels, and regulatory compliance.
- Review complex cases and provide guidance regarding medical necessity, appropriate levels of care, and available services.
- Escalate cases requiring physician review to medical directors or other clinical leaders.
- Collaborate with Case Management to support care coordination, transitions of care, and improved patient outcomes.
- Audit cases and documentation for accuracy, completeness, consistency, and compliance.
- Provide coaching, training, performance feedback, and workload direction to team members.
- Address workflow issues, backlogs, performance gaps, and operational risks.
- Track and report departmental metrics, trends, and areas requiring leadership attention.
- Support health plan, regulatory, and accreditation audits.
- Assist with policy implementation and process improvement initiatives.
- Collaborate with providers, health plans, medical directors, quality teams, and operational departments.
- Maintain departmental stability and performance throughout the interim assignment.
You Will Be Successful If:
- You can quickly assess departmental operations and establish credibility with the team.
- You are a hands-on leader who can effectively manage competing clinical and operational priorities.
- You can lead and support employees in a remote work environment.
- You are comfortable addressing productivity, performance, quality, and compliance issues directly.
- You can interpret performance metrics and use the findings to improve departmental operations.
- You communicate effectively with clinical staff, providers, medical directors, health plans, and operational leaders.
- You can maintain productivity, service levels, and regulatory compliance during a period of organizational transition.
- You balance patient needs, clinical appropriateness, regulatory requirements, and responsible resource utilization.
What You Will Bring:
- Active and unrestricted California Registered Nurse license.
- Previous leadership experience at the supervisor level or above within Utilization Management.
- Direct case management experience.
- Strong experience with utilization review, prior authorization, medical necessity review, care coordination, and transitions of care.
- Experience supervising clinical or healthcare operations staff.
- Knowledge of managed care operations and delegated Utilization Management functions.
- Experience monitoring productivity, quality, compliance, and turnaround-time requirements.
- Ability to review complex cases and determine when physician or medical director escalation is required.
- Strong leadership, communication, organizational, analytical, and problem-solving skills.
- Ability to work independently and lead a team effectively in a remote environment.
- Proficiency with electronic medical records, Utilization Management platforms, and standard business applications.
- Availability to commit to an initial three-month contract.
Preferred Qualifications:
- Bachelor of Science in Nursing.
- CCM, ACM, CPHQ, or another relevant professional certification.
- Experience working with an IPA, medical group, health plan, managed care organization, or delegated-risk organization.
- Experience supporting Medicare Advantage, Medi-Cal, or commercial managed-care populations.
- Experience using InterQual, MCG, or other nationally recognized clinical criteria.
- Familiarity with CMS, California DMHC, DHCS, and applicable accreditation requirements.
- Experience supporting health plan, regulatory, or accreditation audits.
- Previous experience in an interim leadership role or stabilizing a department during a transition.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do: provide tangible results that add immediate value at a rate that cannot be beaten. Your success matters, and we know it.
That’s Impresiv!
