Manager of Utilization Management and Complex Care Management

Job Summary

The Manager of Utilization Management and Complex Care Management provides day-to-day operational leadership for the Utilization Management, Transitional Care, and Care Management teams, supports the execution of processes designed to improve health outcomes, reduce healthcare utilization costs, and facilitate effective care transitions for complex populations. The Manager collaborates closely with the Medical Center leadership, Market Leadership and other stakeholders to ensure a seamless continuum of care across inpatient, ambulatory, and community-based settings.

Acting as a key liaison between staff Medical Center and Market Leadership, the Manager facilitates communication and promotes efficient team operations. Additionally, the Manager oversees performance evaluations, handles disciplinary actions, and works with the leadership team to uphold high service standards. Success in role is measured by meeting and/or exceeding KPI targets around Admissions/1000, Readmissions/1000, Average length of stay and ED Utilization.

 

Duties and Responsibilities

• Team Leadership and Oversight
  • Lead and manage a diverse care management team, including registered nurses, social workers and community health workers.
  • Oversee staff development and ensure adherence to care management standards, including person-centered care planning, SMART goals, and documentation protocols aligned with NCQA, regulatory, and health plan standards.
  • Conduct performance management activities, including case audits, one-on-one coaching, and training, ensuring compliance with quality and accreditation standards.
  • Manage caseloads to ensure follow-up, timely documentation, and compliance with organizational and health plan requirements.
• Collaboration and Interdisciplinary Care
  • Coordinate with community-based organizations, primary care providers, and specialists to address members’ chronic care needs, facilitate transitions of care, and support member retention.
  • Partner with inpatient facility case management departments for collaborative discharge planning and continuity of care.
  • Host and document interdisciplinary care team (ICT) meetings, ensuring follow-up on action items to enhance member outcomes.
• Operational and Performance Improvement
  • Use data and reporting to monitor team performance and drive improvements in utilization, health outcomes, quality metrics, and member satisfaction.
  • Proactively identify low-performing staff or processes, implementing improvement plans or process optimizations as needed.
  • Apply evidence-based guidelines (e.g., MCG, InterQual) to ensure appropriate levels of care, reduce readmissions, and improve transitions.
• Member Engagement and Case Management Expertise
  • Serve as a subject matter expert (SME) on care management, chronic conditions, and organizational information systems, leading training and promoting best practices in member care.
  • Address complex needs of populations with medical, behavioral, and socioeconomic barriers through data-driven interventions and therapeutic approaches such as motivational interviewing and trauma-informed care.
• Stakeholder Relationship Management
  • Develop and maintain relationships with payors, facility leadership, and community organizations to support integrated member care and overcome barriers such as housing, food security, and financial instability.
  • Actively participate in both internal and external meetings, representing the organization’s mission, vision, and values.
• Onboarding, Hiring, and Staff Engagement
  • Conduct interviews, hiring, onboarding, and training for new team members, ensuring alignment with organizational goals.
  • Lead team meetings, engage in team-building activities, and maintain staff morale and productivity through virtual and in-person methods.
  • Responsible for employee engagement scores and staff turnover metrics.
• Additional Responsibilities
  • Maintain the privacy and security of member information as per organizational and legal standards.
  • Adapt to dynamic environments, managing competing priorities and supporting business needs through flexib