Utilization Management Director (RN)

OUR COMMITMENT TO A HUMAN HIRING PROCESS

We believe every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully. 

SERVICE AREA PREFERENCE

While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment. 

We have an opportunity to join the Alliance as the Utilization Management Director (RN) leading the Utilization Management Department. *This is a hybrid position with the expectation to work in our service area(s) approximately 1-2 days per month.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Health Services Executive Director, this position: 

• Leads and shapes the Utilization Management (UM) Strategy for the Alliance while providing management oversight in implementing, directing and monitoring the Utilization Management Department functions, including prior authorizations, concurrent review, medical claims review, appeals and grievance
• Directs the Utilization Management Department, acts as a subject matter expert, and provides direction and advice on the Department’s functions and overall business operations
• Directs, manages and supervises Utilization Management Department staff

ABOUT US

Our mission is to optimize members’ healthcare outcomes through evidenced-based clinical management, stewardship, and collaboration with provider and community partners.

THE IDEAL CANDIDATE

• A strong clinical leader with deep UM expertise who brings sound judgment, regulatory awareness, and a commitment to mission‑driven decision‑making.
• Relationship‑centered and impact‑minded, able to balance oversight of the Utilization Management department with a collaborative approach that maintains trust across internal teams and external partners.
• Strategic, change‑ready, and operationally adept, guiding teams through evolving priorities, articulating organizational shifts with clarity, and advancing process improvements and cross‑functional projects that strengthen UM operations.
• A transparent communicator and mentor, skilled at prioritizing, supporting team growth, modeling accountability, and sustaining momentum while adapting thoughtfully as work evolves.
• A bridge‑builder who sees the big picture, collaborating across functions, presenting confidently, and fostering alignment and cohesion in a fast‑moving environment.

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements, click here. 

• Knowledge of:
• The principles and practices of utilization management 
• The principles and practices of clinical nursing
• Title 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulations
• The principles and practices of managed care
• UM documentation requirements necessary to satisfy regulatory audits
• Ability to:
  • Direct, manage, supervise, mentor, train and evaluate the work of staff
  • Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
  • Develop, plan, organize and direct programs and activities that are complex in nature and regional in scope
  • To identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activities
  • Demonstrate a collaborative management style, build rapport, and effectively manage internal and external business relationships including with members of the medical community, community agencies, and board members
• Education and Experience: