Utilization Management Manager

We are seeking a Utilization Management Manager to lead and oversee Utilization Management operations across multiple IPAs supported by our MSO in Southern California. Reporting to the Head of AI Operations (COO of the MSO), this role is critical to ensuring regulatory compliance, operational excellence, and strong health plan relationships. You will serve as the primary operational point of contact for contracted health plans while leading a team of 5–10 professionals across UM. You will work in partnership with the AI Operations team to implement creative automations and efficiency initiatives. This is an opportunity to build scalable, high-performing workflows and drive measurable improvements in compliance, timeliness, and financial performance. 

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  Provide strategic oversight of all UM operations across multiple IPAs, ensuring regulatory compliance and operational efficiency

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  Lead, mentor, and manage a team of 5–10 UM professionals, setting performance standards and ensuring accountability

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  Serve as the primary operational liaison for contracted health plans, responding to inquiries, performance concerns, reporting requirements, and escalations

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  Oversee all UM-related health plan audits, coordinating preparation efforts and ensuring readiness, accuracy, and timely submission of materials

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  Ensure adherence to regulatory timelines for authorizations and reporting (ODAG logs, timeliness reports, UMC/UMCIS reports)

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  Oversee authorization workflows, queue management, escalation processes, and medical necessity review frameworks

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  Maintain and update UM policies and procedures in alignment with regulatory and health plan requirements

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  Partner with executive leadership to identify process improvements, system enhancements, and automation opportunities to scale MSO operations

• →Create and maintain SOP's for all core workflows

• Minimum 10 years of experience in Utilization Management, Managed Care, or IPA/MSO operations

• Deep expertise in regulatory requirements governing delegated UM functions in California (preferred)

• Experience overseeing health plan audits, delegated oversight reporting, and ODAG logs (preferred)

• Demonstrated experience managing teams in a multi-IPA or delegated risk environment (preferred)

• Strong knowledge of authorization workflows, and medical necessity criteria (preferred)

• MCG Certified (preferred)

• Experience serving as a primary operational contact for health plans (preferred)

• Proficiency in platforms such as EZCap, EZNet, EMR systems, reporting tools (e.g., Crystal Reports), and health plan portals (preferred)

• Exceptional organizational, analytical, and process improvement skills 

• Strong leadership presence with the ability to drive accountability and cross-functional collaboration

• Comfortable working onsite in Chino, CA