Cvs Health Utilization Management Jobs in California

Utilization Management Director

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About this role

The Utilization Management Director will be responsible for building and leading UHSM’s first internal clinical utilization management function. This role will establish the structure, processes, policies, and team supporting end-to-end utilization management and clinical review functions, including medical necessity determinations, prior authorization, concurrent and retrospective review, Shared Medical Bills (SMB) clinical review, appeals support, and associated provider and member communications. 

This is a foundational leadership role for the organization. The Director will partner closely with SMB, Provider Services, Member Services, Compliance, Operations, and executive leadership to establish a clinically sound, compliant, member-centered, and operationally efficient utilization management program.

The ideal candidate is a licensed clinical professional with strong utilization management experience, payer or managed care knowledge, and the ability to build a department from the ground up.

Key Responsibilities

Department Buildout & Clinical Leadership

• Develop and launch UHSM’s internal Utilization Management and Clinical Operations function, including workflows, policies, procedures, staffing models, documentation standards, and performance metrics.
• Inform design and implementation of a Salesforce-based clinical case management platform, partnering with internal and technical teams to define requirements, configure workflows, and optimize utilization management operations. 
• Drive evaluation and selection of a clinical guideline engine (medical necessity criteria tool) and oversee integration with the case management system to support prior authorization, concurrent, and retrospective review workflows.
• Establish clinical review processes for prior authorization, pre-service review, concurrent review, retrospective review, medical necessity review, and SMB-related clinical evaluation and underwriting.
• Build and lead a clinical team, which may include UM nurses, clinical reviewers, care coordinators, clinical operations specialists, and administrative support staff.
• Create clear role definitions, training plans, quality review processes, and performance expectations for clinical team members.
• Serve as the organization’s subject matter expert on utilization management, clinical review operations, and medical necessity processes.

Utilization Management Program Oversight

• Oversee the review of requested healthcare services to support appropriate, evidence-based, timely, and consistent determinations.
• Ensure clinical reviews are based on relevant clinical documentation, plan/program guidelines, recognized clinical criteria, and applicable regulatory or accreditation standards.
• Develop processes for urgent and non-urgent reviews, provider communication, additional information requests, peer review escalation, and documentation of determinations.
• Monitor utilization trends, high-cost services, inpatient stays, readmissions, out-of-network utilization, gaps in care coordination, and other clinical cost drivers.
• Partner with leadership to identify opportunities to improve clinical outcomes, reduce avoidable costs, and strengthen member/provider experience.

Clinical Governance, Compliance & Quality

• Develop policies and procedures aligned with appropriate utilization management standards, including medical necessity review, clinical criteria use, denial documentation, appeals support, and peer review escalation.
• Partner with Compliance to ensure utilization management processes meet applicable federal, state, contractual, and organizational requirements.
• Support audit readiness and maintain accurate documentation for clinical decisions, review rationale, notifications, appeal support, and quality monitoring.
• Establish quality assurance processes to monitor clinical review accuracy, timeliness, consistency, and documentation quality.
• Stay current on utilization management best practices, payer operations, healthcare regulations, and accreditation standards such as NCQA or URAC, as applicable.

Cross-Functional Partnership

• Collaborate with the SMB team to support clinical review of complex SMBs, high-dollar SMBs, disputed SMBs, coding-related clinical questions, and medical necessity concerns.
• Partner with Provider Services to improve provider communication, documentation requests, prior authorization workflows, and provider education.
• Partner with Member Services to ensure clinical review processes are clearly communicated, and member escalations are handled appropriately.
• Work with executive leadership to define the long-term clinical team structure, including future roles such as Medical Director, UM Nurse, Case Manager, Clinical Appeals Nurse, or Care Management Manager.
• Support vendor evaluation and management for clinical review tools, utilization management platforms, medical necessity criteria, peer review vendors, case management resources, or external clinical consultants.

Metrics & Reporting

• Develop dashboards and reporting for utilization management activity, turnaround times, approval/denial trends, appeal outcomes, inpatient days, high-cost services, reviewer productivity, quality audit results, and provider/member escalations.
• Use data to identify process gaps, training needs, cost-containment opportunities, and clinical risk areas.
• Present findings and recommendations to executive leadership in a clear, actionable manner.

Minimum Qualifications

• Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related clinical/healthcare field.
• Active, unrestricted Registered Nurse license or other applicable clinical license required. Multistate Nurse Licensure Compact license preferred. Candidate must be eligible and willing to obtain additional state licensure if required based on organizational needs, member geography, applicable regulations, and assigned clinical responsibilities.
• 7+ years of healthcare experience, including significant experience in utilization management, managed care, payer operations, clinical review, case management, or health plan operations.
• 5+ years of leadership experience managing clinical staff, UM nurses, case managers, or healthcare operations teams.
• Demonstrated experience managing departmental budgets, including headcount planning, vendor spend, and operational cost oversight
• Strong knowledge of utilization management functions, including prior authorization, medical necessity review, concurrent review, retrospective review, appeals support, and clinical documentation requirements.
• Experience using evidence-based clinical criteria, such as MCG, InterQual, Medicare guidelines, plan guidelines, or similar review criteria.
• Experience developing or improving clinical workflows, policies, procedures, training materials, and quality review processes.
• Strong understanding of payer, TPA, managed care, health plan, or healthcare cost-containment operations.
• Ability to build a department, lead change, influence cross-functional partners, and create structure in a developing environment.
• Strong analytical skills with the ability to interpret utilization trends, claims data, clinical review data, and operational metrics.
• Excellent communication skills, including the ability to explain clinical review decisions, process requirements, and policy recommendations to both clinical and non-clinical stakeholders.

Preferred Qualifications