intus - Utilization Management Manager

• TEAM LEADERSHIP & PERFORMANCE MANAGEMENT (APPROXIMATELY 75% OF TIME) • Hold full accountability for UM team performance, including meeting or exceeding all program SLAs (turnaround times, decision timeliness, dispute resolution timelines, documentation completeness, and quality benchmarks). • Establish, monitor, and report on individual and team performance metrics; conduct regular one-on-ones, performance reviews, and coaching sessions to drive accountability and professional growth. • Ensure consistent application of PACE service authorization policies, standard operating procedures, and clinical decision support criteria (e.g., MCG) across every reviewer and every case. • Design and lead ongoing quality assurance (QA) and inter-rater reliability activities; identify variance in decision-making, address it through targeted coaching or process changes, and document outcomes. • Manage staffing, scheduling, workload distribution, and case assignment to ensure sustained SLA performance during volume fluctuations, coverage gaps, and PTO. Perform case reviews as needed during staff PTO to assure timely case completion and accuracy. • Recruit, onboard, and develop UM nurses; build competency-based training programs and structured ramp plans for new hires. • Foster a culture of accountability, collaboration, psychological safety, and continuous improvement. • Maintain and update UM policies, procedures, workflows, and job aids; ensure changes are communicated, trained on, and audited for adoption. • Partner with the contracted IntusCare Contracted Physician to define escalation pathways and ensure clinical decision-making support is available when needed. • Use data analytics to monitor care patterns, cost drivers, length-of-stay trends, denial and overturn rates, and utilization efficiency; translate findings into targeted improvement initiatives. • Lead or sponsor rapid-cycle performance improvement initiatives across UM functions. • Prepare and present program performance reporting to internal leadership and PACE client stakeholders. • DIRECT UM CASE & DISPUTE WORK (APPROXIMATELY 25% OF TIME) • Personally handle a defined caseload of UM reviews and provider disputes to remain clinically current, model expected practice, and manage escalations. This includes: • ◦ Initial and Concurrent review of hospital admissions (observation and inpatient) with the PACE primary care and IDT teams, driving efficient and timely transitions of care, and retrospective review of inpatient admissions under 48 hours and claims submitted inconsistent with the service authorization. • ◦ Concurrent review of subacute and SNF admissions with the IDT, driving efficient and timely discharge plans and transitions of care. • Lead the provider dispute process on complex or escalated cases, including: • ◦ Comprehensive review of provider network disputes. • ◦ Collaboration with the PACE program's finance and claims adjudication team to coordinate clinical review supporting disputed claims. • ◦ Collaboration with the IntusCare Contracted Physician to review and respond to disputes, ensuring written determinations consistent with IntusCare policies. • STAKEHOLDER ENGAGEMENT & COMMUNICATION • Partner with PACE organizations, Medical Directors, IDTs, and provider networks to strengthen communication and ensure alignment on authorization decisions and care strategies. • Facilitate education, training, and cross-functional collaboration to improve UM consistency, documentation accuracy, and compliance with IntusCare standards. • Serve as one of the primary points of contact and accountable owner for IntusCare UM program performance in client-facing meetings. • ACCOUNTABILITY & SUCCESS MEASURES • The UM Manager will be evaluated against outcomes including, but not limited to: • Achievement of all UM program SLAs, including authorization decision turnaround times and dispute resolution timelines. • Inter-rater reliability scores and QA audit results demonstrating consistent application of policies, procedures, and clinical decision support criteria. • Team engagement, retention, and time-to-productivity for new hires. • Timeliness, accuracy, and defensibility of dispute determinations.