Utilization Care Manager Jobs in Reston, VA (NOW HIRING)

The Nurse Director, Focused Care Management role is responsible for leading enterprise care management and population health programs that support quality, utilization, and value-based performance across multiple patient populations. The role provides strategic oversight of Diabetes Care Management, Nutrition Services, CHF, Memory Care, and Cervical Cancer Screening programs, driving clinical excellence, operational performance, care coordination, regulatory readiness, and continuous improvement initiatives. Working collaboratively with clinical and operational leaders, this position ensures effective program integration, resource stewardship, workforce engagement, and achievement of key patient care and organizational outcomes.

In addition to the responsibilities below, this position is also responsible for establishing best practice models; designing patient care delivery systems and practice standards across the service line(s), locations, and programs; leading the investigation of patient/family/member concerns regarding patient care and services; partnering with physicians, outside healthcare providers, and other health care team members to achieve optimal and safe patient care across the continuum; managing resource needs in clinical areas to ensure appropriate assignment and utilization; directing the use and maintenance of equipment, supplies and medications; assuming accountability for patient and employee safety; maintaining clinical expertise of self and/or team, providing clinical supervision, competency and licensing necessary to fulfill job responsibilities and to direct the provision of care in the unit; delegating tasks and duties that are aligned to scope of practice; and performing clinical duties as required.

• Prepares individuals for growth opportunities and advancement; builds internal collaborative networks for self and others. Solicits and acts on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Demonstrates continuous learning; oversees the recruitment, selection, and development of talent; ensures performance management guidelines and expectations to achieve business needs. Stays up to date with organizational best practices, processes, benchmarks, and industry trends; shares best practices within and across teams. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact.
• Oversees the operation of multiple units within a department by identifying member and operational needs; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
• Directs continuum of care / care at home operations to support patient care by: approving timelines and developing and/or directing strategy with stakeholders to identify factors contributing to business value; assuming accountability for department performance targets and aligning with market strategies; championing short- and long-term operational initiatives and directing program, services, and/or systems development; aligning human resource management programs (e.g., performance measurement and employee management) with KPs mission and values; designing continuous survey and compliance readiness activities, including mock rounds and mitigating issues, to maintain compliance and regulatory standards and reviewing prepared audit documentation, information, and reports; and leading the development of budgets for assigned areas (e.g., branch office, staffing, business services departments) and ensuring overall financial performance meets expectations.
• Ensures standardized care delivery by: partnering with physicians and other clinical leaders to align key care delivery initiatives across KP, providing oversight of all workstreams; assuming accountability for short- and long-term results and performance while ensuring guideline and regulation alignment for service lines or programs; driving cross-functional patient management resolution with internal and external leaders, ensuring consistency and seamless transitions across the continuum of care; anticipating and aligning resources in clinical areas to ensure appropriate assignment and utilization for service lines or programs; directing multidisciplinary continuum of care / care at home team(s) and holding team(s) accountable for performance; ensuring appropriate oversight to maintain high quality contract/vendor relations that provide optimal patient care and medical services for care across the continuum; planning long-term strategic goals and designing emergency preparedness programs and ensuring the departments emergency preparedness and recovery plans are current and that managers and staff are trained and know what is expected during and after an emergency; and providing strategic direction to project teams leading initiatives and ensuring implementation, equitable distribution of resources, and delivery on objectives.
• Directs improvements to operations and technology processes by: driving KP-wide internal and external strategic projects designed to remediate issues for impacted groups and improve quality, service, affordability, and/or operating efficiency; ensuring clinical teams use standardized tools to identify root causes for escalations, making recommendations, and implementing solutions to improve the performance of operations system processes; and consulting with senior and executive management to identify relevant performance metrics to monitor the success of strategic improvement projects.

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Constructive Feedback
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Leadership
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Strategic Thinking
• Team Building
• Teamwork
• Topic-Specific Communication

• Emergency Preparedness
• Evidence-Based Medicine Principles
• Evidence-Based Practices
• Licensure Principles
• Nursing Principles
• Patient Safety
• Business Process Improvement
• Calendar Management
• Change Management
• Compliance Management
• Confidentiality
• Conflict Resolution
• Employee Training
• Employee/Labor Relations
• Financial Acumen
• Health Care Compliance
• Health Care Quality Standards
• Information Systems
• Legal And Regulatory Requirements
• Maintain Files and Records
• Member Service
• Microsoft Office
• Onboarding
• Outcome Driven Innovation
• Position Requirements
• Stakeholder Management
• Talent Management
• Training
• Union Work Environment
• Vendor Management
• Workforce Planning

• Bachelors degree in Nursing (BSN) AND minimum seven (7) years of experience in business operations, clinical health care, or a directly related field.
• Minimum two (2) years of experience in a leadership role with direct reports.
• Minimum five (5) years of customer or member/patient service experience.
• Minimum two (2) years of experience managing operational or project budgets.

• Basic Life Support required at hire

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.

• Registered Nurse License (Maryland) within 6 months of hire AND Registered Nurse License (Virginia) within 6 months of hire

1. OR

• Compact License: Registered Nurse within 6 months of hire

• Registered Nurse License (District of Columbia) within 6 months of hire

• Five (5) years of project/program management and/or implementation-related experience.
• Five (5) years of experience in process improvement.