Utilization Management Director (RN)

OUR COMMITMENT TO A HUMAN HIRING PROCESSWe believe every candidate deserves thoughtful consideration.That'swhy we do not use AI or automated systems toreview applications . Every application is reviewed bya real human member of our team. Because we take the time to give each submission the attention it deserves, our review process may take a little longer - and we genuinely appreciate your patience as we work through applications carefully and respectfully.SERVICE AREA PREFERENCEWhile we encourage all interested applicants to apply, we do give priority to those who live in , or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa . Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.We have an opportunity to join the Alliance as the Utilization Management Director (RN) leading the Utilization Management Department. *This is a hybrid position with the expectation to work in our service area(s) 1-2 days per month.WHAT YOU'LL BE RESPONSIBLE FORReporting 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 grievanceDirects the Utilization Management Department, acts as a subject matter expert, and provides direction and advice on the Department's functions and overall business operationsDirects, manages and supervises Utilization Management Department staffABOUT USOur mission is to optimize members' healthcare outcomes through evidenced-based clinical management, stewardship, and collaboration with provider and community partners.THE IDEAL CANDIDATEA strong clinical leader with deep UM expertise who brings sound judgment, regulatory awareness, and a commitment to missiondriven decisionmaking.Relationshipcentered and impactminded , able to balance oversight of the Utilization Management department with a collaborative approach that maintains trust across internal teams and external partners.Strategic, changeready, and operationally adept , guiding teams through evolving priorities, articulating organizational shifts with clarity, and advancing process improvements and crossfunctional 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 bridgebuilder who sees the big picture , collaborating across functions, presenting confidently, and fostering alignment and cohesion in a fastmoving environment.WHAT YOU'LL NEED TO BE SUCCESSFULTo read the full position description and list of requirements, click here .Knowledge of:The principles and practices of utilization managementThe principles and practices of clinical nursingTitle 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulationsThe principles and practices of managed careUM documentation requirements necessary to satisfy regulatory auditsAbility to:Direct, manage, supervise, mentor, train and evaluate the work of staffProvide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issuesDevelop, plan, organize and direct programs and activities that are complex in nature and regional in scopeTo identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activitiesDemonstrate 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 membersEducation and Experience:Current unrestricted license as a Registered Nurse issued by the state of CaliforniaBachelor's degree in NursingA 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 qualifyingOTHER INFORMATIONWe 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 INFORMATIONThe hiring ranges below represent a goodfaith 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 careers@thealliance.health , 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 areasTypical areas in Zone 2: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento)Zone 1 (Monterey, San Benito and Santa Cruz) $213,000 — $245,000 USD Zone 2 (Mariposa and Merced) $200,000 — $230,000 USDOUR BENEFITSAvailable for all regular Alliance employees working more than 30 hours per week.Some benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.Medical, Dental and Vision PlansAmple Paid Time Off12 Paid Holidays per year401(a) Retirement Plan457 Deferred Compensation PlanRobust Health and Wellness ProgramOnsite EV Charging StationsABOUT USWe are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet .The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employerAt this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.