Utilization Management Manager

Vālenz^® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.
 

About This Opportunity: 

As a Utilization Management Manager, you’ll provide oversight and operational leadership for the Utilization Management Program. You will ensure these services are delivered effectively and efficiently, aligning with the company’s high standards for quality and cost-effectiveness along with managing the day-to-day operations and driving continuous improvements and innovations in care management practices. 

Things You’ll Do Here:  

• Oversee, evaluate, and maintain clinical program productivity, KPIs, and performance standards. 
• Generate and analyze outcome reports to guide staff in improving clinical and financial outcomes for clients. 
• Implement enhanced quality review processes for timely supervisory case reviews. 
• Ensure adherence to confidentiality, HIPAA standards, and URAC compliance. 
• Maintain compliance with federal, state, and local regulations. 
• Conduct annual performance evaluations, create improvement plans, and manage staff terminations. 
• Lead hiring, training, and development of new care staff. 
• Collaborate with the VP, Care Management on performance-related issues. 
• Spearhead accreditation efforts, focusing on successful URAC reaccreditation. 
• Ensure current products are delivered effectively and utilize best practices to develop opportunities for improvements. 
• Develop and maintain knowledge of cultural differences and socioeconomic factors affecting care. 
• Collaborate with other departments for integrated administrative activities and clinical operations. 
• Promote coordination and communication within the company regarding quality improvement and clinical operations. 

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties. 

What You’ll Bring to the Team: 

• Bachelor’s degree in Nursing (BSN) or related education degree. 
• Five (5) or more years of experience in a supervisory role managing health care programs and associated clinical staff. 
• Five (5) or more years of experience in utilization management, capable of effectively handling cases across all age groups and a wide range of medical conditions.   
• Experience with MCG (Milliman Care Guidelines) and NCCN for clinical reviews. 
• Experience in a managed health care program setting, with a deep understanding of utilization management. 
• Proficient knowledge of NCQA, URAC, or similar accreditation standards and previous participation in accreditation surveys. 
• Excellent communication and interpersonal skills, capable of effectively engaging with healthcare professionals, clients, and stakeholders at all levels. 
• Demonstrated ability to implement strategic plans, adhere to budgets, and provide insights for efficient operation and growth. 
• An active, unrestricted RN license in the state of residence, including a compact license. 
• Certification in a URAC recognized field. 

A plus if you have 

• MSN, MBA, or related degree in healthcare administration. 
• MCG Certification  
• Knowledge of self-funded plans, MGU, or stop-loss. 
   

Where You’ll Work: This is a fully remote position, and we’ll provide all the necessary equipment!  

• Work Environment: You’ll need a quiet workspace that is free from distractions. 
• Technology: Reliable internet connection—if you can use streaming services, you’re good to go! 
• Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software. 
• Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA. 

Why You'll Love Working Here

Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare. With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do.

Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting
• Flexible working environment
• Generous Paid Time Off to include vacation, sick leave, and paid holidays
• Employee Assistance Program that includes professional counseling, referrals, and additional services
• Paid maternity and paternity leave
• Pet insurance
• Employee discounts on phone plans, car rentals and computers
• Community giveback opportunities, including paid time off for philanthropic endeavors

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.