Utilization Management Director (RN)

We have an opportunity to join the Alliance as the Utilization Management Director (RN) leading the Utilization Management Department. 

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Health Services Executive Director, this position: 

• Leads and shapes the Utilization Management (UM) Strategy for the Alliance while providing management oversight in implementing, directing and monitoring the Utilization Management Department functions, including prior authorizations, concurrent review, medical claims review, appeals and grievance
• Directs the Utilization Management Department, acts as a subject matter expert, and provides direction and advice on the Department’s functions and overall business operations
• Directs, manages and supervises Utilization Management Department staff

ABOUT US

Our mission is to optimize members’ healthcare outcomes through evidenced-based clinical management, stewardship, and collaboration with provider and community partners.

THE IDEAL CANDIDATE

• A strong clinical leader with deep UM expertise who brings sound judgment, regulatory awareness, and a commitment to mission‑driven decision‑making.
• Relationship‑centered and impact‑minded, able to balance oversight of the Utilization Management department with a collaborative approach that maintains trust across internal teams and external partners.
• Strategic, change‑ready, and operationally adept, guiding teams through evolving priorities, articulating organizational shifts with clarity, and advancing process improvements and cross‑functional projects that strengthen UM operations.
• A transparent communicator and mentor, skilled at prioritizing, supporting team growth, modeling accountability, and sustaining momentum while adapting thoughtfully as work evolves.
• A bridge‑builder who sees the big picture, collaborating across functions, presenting confidently, and fostering alignment and cohesion in a fast‑moving environment.

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements, click here. 

• Knowledge of:
• The principles and practices of utilization management 
• The principles and practices of clinical nursing
• Title 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulations
• The principles and practices of managed care
• UM documentation requirements necessary to satisfy regulatory audits
• Ability to:
  • Direct, manage, supervise, mentor, train and evaluate the work of staff
  • Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues
  • Develop, plan, organize and direct programs and activities that are complex in nature and regional in scope
  • To identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activities
  • Demonstrate a collaborative management style, build rapport, and effectively manage internal and external business relationships including with members of the medical community, community agencies, and board members
• Education and Experience:
  • Current unrestricted license as a Registered Nurse issued by the state of California
  • Bachelor’s degree in Nursing
  • A minimum of ten years of utilization management experience which included a minimum of five years of experience in a managed care environment and three years of staff management experience (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment, and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

COMPENSATION INFORMATION

The hiring ranges below represent a good‑faith estimate of what we expect to pay for this role upon hire and are not the full compensation ranges. Employees typically have opportunities for growth within the full compensation range over time based on performance and merit. Final compensation will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience related to the position, education, or training), as well as other factors (internal equity, market factors, and geographic location).

The applicable salary ranges are based on work location and are aligned to a zone according to the cost of labor in your area. All ranges are subject to change in the future. We are happy to provide the full compensation range for the role, answer any questions that you have, or share the applicable pay zone for your location if it’s not one of the typical areas included below. You can reach out to [email protected], and a member from our Talent Acquisition team will be in touch.

Typical areas in Zone 1: Santa Cruz, San Benito, and Monterey Counties, Bay Area, Sacramento, Los Angeles and San Diego areas

Typical areas in Zone 2: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento)