Manager Utilization Management Administration ...

Role OverviewUnder the supervision of the Director of Utilization Management Administrative Operations and Audit, this position is responsible for providing daily oversight of the Utilization Management Correspondence team. In this role, you will provide clinical, technical and operational support and direction, including organization and monitoring of all medical services. This role provides oversight of professional and front-line staff, receiving requests for notification of authorization determinations from external customers which encompasses providers and members, as well as from the internal customers.Work Arrangement Remote role Monday through Friday, 8:00 AM EST to 5:00 PM EST Ability to work weekends (rotating) and holidays based on business needs Responsibilities Manages and maintains all regulatory requirements for all members and provider notifications and works in collaboration with other leadership in different lines of business to maintain contractual compliance with notifications. Provides oversight of the daily operations of licensed professionals on the Utilization Admin Ops and Correspondence team. Oversees and manages staff responsible for all letter-elated tasks and requirements, including New/Updating template implementation process Maintaining/overseeing the approved templates for new business when there is not a mandated letter template from the state or other accrediting body. Maintaining/overseeing the approved templates and ensuring updates are made timely if change is received from a state or accrediting body. Oversee the management of the delegate letter process: creation, review, approval, configuration and testing process. Oversee/escalate any delegate letter issues of noncompliance expeditiously. Provides oversight to the dedicated team trained in correspondence/communication requirements for all denials and any additional informational letters that need issued in accordance with state/plan or accrediting body requirements. Assesses candidates and ensures that optimal qualifications are met as a member of the department's interview team. Plans, develops and supports or conducts orientations, training programs and creates educational material for staff members to improve skills, aid in professional growth and development and to ensure staff's expertise. Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance. Works collaboratively with the Director and other identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans. Responsible for writing and finalizing annual reviews for direct reports with Director input. Participates in process reviews and the development of new and/or revised work processes, policies and procedures relating to Utilization Review Correspondence process. Acts as a liaison with outsides entities, including, but not limited to, delegated vendors, and regulatory agencies. Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with internal and external customers, providers and members at all times. Stays current with ACFC policies and procedures and Medicaid, Medicare and Marketplace requirements. Education and Experience Bachelor of Science in Nursing (BSN) Minimum of 3 years of progressive experience in an acute care setting Minimum 3 years utilization management review in a managed care organization Experience managing a remote team of utilization management reviewers Experience operationalizing individual state contract requirements, translating complex legal contract language into day-to-day operational workflows Experience managing and maintaining NCQA standards and CMS guidelines as it relates to work processes, policies and procedures for approval and denial correspondence to both members and providers Licensure Current and unencumbered Nurse Licensure Compact (NLC) Skills and Abilities Proficiency with Microsoft Office Suite Ability to type with speed and accuracy Your career starts now. We're looking for the next generation of health care leaders.At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.Discover more about us at .Our Comprehensive Benefits PackageFlexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.As a company, we support internal diversity through:Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

Created: 2026-03-04