At Collective Health, we’re transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology, compassionate service, and world-class user experience design.
The UM Program Manager will play a critical role in the strategic development, effective and efficient delivery, and ongoing management of utilization management (UM) programs. The person in this role will own and be accountable to the success of Collective Health’s UM programs. To this end, the UM program manager will ensure that our processes are proactively aligned with industry best practices, regulatory requirements, and client-specific needs; provide clinical oversight, manage partner relationships, and drive process improvements; and collaborate with internal and external stakeholders to ensure cost-effective and medically-appropriate health care services
What you'll do:Strategic Leadership and Program Development:
- Implement a comprehensive program to manage clinical UM and Prior Authorizations oversight with a focus on scalability and sustainability, including establishing policies, procedures, and workflows that ensure efficient and consistent program execution, and align with best practices, regulatory requirements (e.g., NCQA, URAC), client needs, and the TPA's values.
- Plan for future program growth, including identifying and recruiting staff with relevant skill sets over a 3-5 year horizon.
- Define the long-term goals and direction for the UM service line in collaboration with senior leadership.
- Continuously analyze processes and data to find inefficiencies and implement innovative solutions for better outcomes and cost management.
- Contribute to broader organizational goals by developing strategies related to medical management, risk adjustment, and overall healthcare delivery.
Clinical Expertise and Collaboration:
- Assume clinical ownership of UM and prior authorization services delivered through current and potential vendor partners, ensuring adherence to quality standards and contractual obligations.
- Serve as the primary clinical point of contact for UM partners, fostering collaborative relationships and driving performance improvements.
- Conduct regular audits of UM performance and participate in case reviews, identifying and addressing areas for improvement.
- Serve as an internal subject matter expert on medical necessity criteria, evidence-based guidelines, and accepted standards of medical practice.
- Maintain a deep understanding of current UM practices, regulatory requirements, and industry trends.
- Work collaboratively with internal clinical and product teams to provide updates on program performance and ensure seamless program integration and alignment.
- Contribute to the company's fund of knowledge and expertise by educating internal stakeholders on relevant UM-related topics
- Bachelor's degree in Nursing, Healthcare Administration, or a related clinical field (Master's preferred).
- Active unrestricted Registered Nurse (RN) license.
- Minimum of 5 years of direct clinical patient care experience.
- Minimum of 5-7 years of operational and management experience with utilization management, prior authorization, or related roles.
- Strong knowledge of UM and prior authorization practices, metrics, regulatory requirements, and industry trends.
- Experience managing vendor relationships, including clinical oversight.
- Mastery of coding for prior authorizations
- Strong analytical, problem-solving, and decision-making skills.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively in a fast-paced environment.
- Experience with healthcare technology platforms and data analysis tools.
- Experience working with TPAs or health plans.
This is a hybrid position based out of one of our offices: San Francisco, CA, Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office two days per week.#LI-hybrid
The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.
- Mission-driven culture that values innovation, collaboration, and a commitment to excellence in healthcare
- Impactful projects that shape the future of our organization
- Opportunities for professional development through internal mobility opportunities, mentorship programs, and courses tailored to your interests
- Flexible work arrangements and a supportive work-life balance
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Collective Health is committed to providing support to candidates who require reasonable accommodation during the interview process. If you need assistance, please contact [email protected].
Privacy NoticeFor more information about why we need your data and how we use it, please see our privacy policy: https://collectivehealth.com/privacy-policy/.
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What We Do
Collective Health is a technology company simplifying employer healthcare to make health insurance work for everyone. With more than a quarter million members and over 60 enterprise clients—including Pinterest, Restoration Hardware, and more—our technical and customer experience teams are reinventing the healthcare experience for employers and their people.
Why Work With Us
Collective Health has a mighty mission—to make the American healthcare system effortless—and a culture focused empathy, authenticity, curiosity, and a need to solve hard problems. We have a diverse, mission-driven team with doctors working alongside data scientists and nuclear engineers to reinvent the the healthcare experience for everyday people.
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