Manager Optum Utilization Review Jobs in Riverside, CA

Position Summary

The Manager of Case Management & Social Services is responsible for the overall leadership, management, and daily operations of the Case Management and Social Services departments. This position provides strategic and operational oversight to ensure the delivery of high-quality, patient-centered care coordination, discharge planning, utilization management, and psychosocial services across the continuum of care. The Manager collaborates with physicians, nursing leadership, ancillary departments, post-acute providers, and community agencies to promote safe, timely, and efficient patient transitions while supporting regulatory compliance, quality outcomes, and financial stewardship. 

The Manager oversees a multidisciplinary team of registered nurse case managers, licensed clinical social workers, social workers, case management assistants, and other support staff. Responsibilities include supervising departmental operations, developing and implementing policies and procedures, monitoring key performance indicators, managing departmental budgets, ensuring compliance with federal, state, and accreditation standards, and fostering a culture of collaboration, accountability, and continuous improvement. 

This role is instrumental in reducing avoidable hospital days, improving patient flow, minimizing readmissions, optimizing resource utilization, and enhancing the patient and family experience. The Manager serves as a key leader in interdisciplinary care coordination, utilization review, complex discharge planning, population health initiatives, and value-based care strategies. The position also works closely with executive leadership to achieve organizational goals related to quality, patient safety, operational efficiency, regulatory compliance, and financial performance. 

The Manager of Case Management & Social Services promotes professional development, staff engagement, and evidence-based practice while ensuring equitable access to healthcare resources and advocacy for patients and families. This leader is expected to maintain strong relationships with skilled nursing facilities, home health agencies, hospice organizations, community resources, behavioral health providers, and payer organizations to facilitate seamless transitions of care and improve health outcomes. 

What You'll Do (not all inclusive)

• Assumes a leadership/supervisory role by assisting with the daily operations/functions of the department including scheduling, InterQual reviews, staff assignments, orientation of new staff members, and completion of Treatment Authorization Request (TAR) forms. 

• Functions as the liaison to the Medi-Cal Managed Care program, medical records, and the central business office. 

• Develops and maintains Case management policies and procedures. 

• Collaborates in writing appeals for denials, as necessary. 

• Coordinates with outside agencies including but not limited to CPS/APS and psychiatric services and shares information with associates. 

• Coordinates Riverside County 5150 training and certification process for all SGMH designated 5150 evaluators. 

• Under the direction of the Chief Nursing Officer, generates, revises, and updates Utilization Management plans, policies, and procedures and coordinates the implementation of Case Management/Risk Management/Utilization Management activities within the hospital. 

• Assists in providing in-services on CM/InterQual Reviews/UM philosophy, policies, and procedures as needed; coordinates distribution of educational material on CM/InterQual Reviews/UM topics to appropriate hospital personnel. 

• Coordinates concurrent review studies performed within the CM/InterQual Reviews/UM Program and prepares resulting reports. 

• Manages the Social Services Department. 

• Consistently places patient safety as the highest priority. 

• Actively participates on Hospital Committees, as required. Assists with facilitation of the Utilization Management Committee. 

• Maintains and reports statistical information on admissions, LOS, etc. Maintains communication and promotes cooperation with other Departments. 

Minimum Qualifications

Education

• Bachelor’s degree in Nursing (BSN), Social Work (BSW), Healthcare Administration, or another healthcare-related field from an accredited college or university. 

 Experience

• Three (3) years of progressively responsible experience in acute care case management, utilization management, social services, care coordination, or discharge planning in hospital settings. 

• Demonstrated knowledge of CMS Conditions of Participation, Joint Commission standards, California Title 22 regulations, utilization review, discharge planning, and payer requirements. 

• Experience leading both Case Management and Social Services departments. 

• Experience with value-based care, population health, denial management, and multidisciplinary care coordination. 

• Experience with electronic health records, case management software, and performance improvement initiatives. 

• Experience with electronic health records, case management software, and performance improvement initiatives. 

Required Licenses & Certifications

Candidates must possess and maintain:

• Registered Nurse (RN) issued by the California Board of Registered Nursing. 

• Current Basic Life Support (BLS) certification. 

• Valid CA Driver's License may be required if travel between facilities is necessary. 

Other Skills

• Commitment to patient advocacy, cultural competence, confidentiality, and patient-centered care. 

• Ability to establish and maintain effective working relationships with internal and external stakeholders, including skilled nursing facilities, home health agencies, hospice providers, behavioral health organizations, and community resources. 

• Knowledge of quality improvement methodologies, including Lean, Six Sigma, or other performance improvement frameworks is preferred. 

• Ability to maintain confidentiality and exercise sound judgement in handling sensitive patient, personnel, and organizational information. 

What We're Looking For

Successful candidates demonstrate:

• Exceptional customer service and interpersonal skills.
• Professionalism, integrity, and sound judgment.
• Strong verbal and written communication skills.
• Strong analytical thinking and the ability to manage multiple tasks concurrently.
• Able to work in, manage and deal with stressful situations.
• The ability to remain calm and make sound decisions during emergencies.
• Effective conflict resolution and de-escalation skills.
• Strong observation, investigative, and report-writing abilities.
• Computer proficiency, including security systems and Microsoft Office applications.

Compensation & Benefits

Pay

• Competitive compensation is based on experience, education, certifications, and applicable licensure.

Benefits (eligibility varies based on employment status)

We offer a comprehensive benefits package that may include:

• Medical, dental, and vision insurance
• Basic Life and AD&D insurance
• Supplemental life insurance (employee, spouse, and/or child)
• Flexible Spending Accounts (Medical and Dependent Care)
• 403(b) retirement plan with employer match up to 5%
• Paid Time Off (PTO)
• Employee wellness resources
• Professional development and training opportunities

At San Gorgonio Memorial Hospital, we are committed to creating a safe, respectful, and compassionate environment for our patients, visitors, and one another. If you are looking for a meaningful career where your work has a direct impact on the health and safety of your community, we encourage you to apply today.

M/F/D/V/SO

EOE