Medicare Utilization Management Program Manager Jobs

Are you an experienced nursing leader with a passion for utilization management, operational excellence, and team development? P3 Health Partners is seeking a Utilization Management Manager to oversee the daily operations of our Utilization Management (UM) department and help drive quality, efficiency, and compliance across the organization.

In this leadership role, you'll guide a team of UM professionals, collaborate with key clinical and operational stakeholders, and play a vital role in ensuring members receive the right care at the right time. You'll have the opportunity to influence processes, mentor staff, support organizational growth, and contribute to initiatives that improve both patient outcomes and healthcare value.

As the Utilization Management Manager, you'll provide leadership, oversight, and expertise to ensure the UM department operates effectively while meeting regulatory and organizational standards.

• Lead and manage the daily operations of the Utilization Management department, including staff supervision, coaching, and performance management.
• Monitor departmental workflows to ensure efficiency, accuracy, and compliance with applicable regulations and organizational requirements.
• Serve as a subject matter expert and resource for UM staff, providing ongoing education, mentorship, and support.
• Promote a culture of quality, accountability, and continuous improvement across the department.
• Participate in Utilization Management and Quality Assurance committees and support organizational quality initiatives.
• Assist with preparation for and participation in audits conducted by health plans, NCQA, CMS, and other regulatory entities.
• Collaborate with cross-functional teams including Case Management, Clinical Operations, Quality Improvement, Claims, Network Development, Configuration, and Finance.
• Develop, implement, and maintain departmental policies, procedures, and workflow standards.
• Identify process improvement opportunities and provide recommendations for system enhancements and operational efficiencies.
• Maintain expertise in Medicare Advantage regulations, managed care requirements, and provider/facility contract provisions.
• Partner with Medical Directors to support medical necessity determinations and coordination of care activities.
• Participate in strategic planning, budgeting activities, and organizational growth initiatives.
• Support implementation efforts related to new markets, programs, and business expansion.

You are a collaborative healthcare leader who balances strong clinical knowledge with operational expertise and a commitment to excellence.

• Comprehensive knowledge of Medicare Advantage regulations, utilization management practices, and healthcare compliance requirements.
• Strong leadership and team development skills.
• Excellent verbal and written communication abilities, including presenting complex information to diverse audiences.
• Strong organizational and project management capabilities.
• Ability to prioritize competing demands in a fast-paced environment.
• Sound judgment, critical thinking, and decision-making skills.
• Ability to foster strong relationships across departments and levels of the organization.
• Experience utilizing referral management systems, MCG criteria, CMS guidelines, and payer portals.
• Continuous improvement mindset focused on quality, efficiency, and member outcomes.

• Graduate of an accredited school of nursing.
• Active, unrestricted Registered Nurse (RN) license in the state of Arizona, California, Nebraska, Nevada, or Oregon.
• Ability to obtain licensure in all delegated markets within one year of hire.
• Minimum of five (5) years of clinical nursing experience.
• Minimum of two (2) years of experience within managed care, an HMO, or a global risk-bearing provider organization.
• Minimum of two (2) years of supervisory or management experience.
• Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.

• Bachelor's degree in Nursing (BSN).
• Experience leading utilization management teams within a Medicare Advantage environment.
• Experience supporting regulatory audits and accreditation activities.

• Monday - Friday; occasional oversight of Saturday/Sunday progress; 8 AM - 5 PM CT

• This role offers a hybrid work arrangement. Candidates will follow our hybrid schedule, working in office three days per week.

• Occassional travel to delegated markets (currently AZ, CA, NE, NV, OR).

Salary Range: $100,000 - $140,000 annually.

The posted salary range reflects P3 Health Partners' good-faith estimate for this role at the time of posting. Placement within the range will be based on qualifications, experience, education, geographic location, and internal equity considerations. In addition to base salary, eligible employees may have access to a comprehensive benefits package and other compensation opportunities.

People. Passion. Purpose.

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives, and engage patients. We are a physician-led organization relentless in our mission to overcome obstacles and positively disrupt the business of healthcare, transforming it from sickness care into wellness guidance.

As a Utilization Management Manager, you'll play a critical role in helping ensure our members receive high-quality, coordinated, and cost-effective care. You'll work alongside dedicated healthcare professionals and leaders who are committed to innovation, collaboration, and improving the healthcare experience for both patients and providers.

At P3, you'll have the opportunity to make a meaningful impact while growing your career in a fast-paced and evolving organization. If you are passionate about your work, eager to have fun, and motivated to be part of a mission-driven team, we encourage you to join us.

Help shape the future of healthcare while leading a team committed to clinical excellence and positive patient outcomes.