Program Manager (Care & Utilization Management)

1. CM/UM TransformationLead strategic transformation initiatives across Care Management, Utilization Management, Prior Authorization, Case Management, Disease Management, and Population Health.Establish standardized enterprise processes while supporting state-specific regulatory requirements.Identify opportunities to reduce administrative burden, improve member/provider experience, and lower medical costs.Drive automation and AI-enabled workflows across authorization and care management.2. Program LeadershipManage a portfolio of concurrent CM/UM initiatives across multiple states and lines of business.Establish program governance, roadmaps, milestones, dependencies, risks, and financial targets.Coordinate business, clinical, technology, data, compliance, actuarial, and vendor stakeholders.Present program status, issues, financial performance, and strategic decisions to executive leadership.3. Utilization ManagementLead initiatives involving prior authorization, concurrent review, retrospective review, medical necessity, and utilization optimization.Support compliance with CMS, state Medicaid, NCQA, URAC, and other applicable requirements.Improve turnaround times and reduce provider abrasion.Identify opportunities to leverage clinical intelligence, automation, and AI to improve authorization decisions and workflows.4. Care ManagementTransform case management, disease management, transitions of care, and complex care programs.Improve identification and stratification of high-risk/high-cost members.Integrate claims, clinical, pharmacy, social determinants, and provider data to improve care interventions.Establish measurement frameworks for clinical outcomes, member engagement, and medical-cost impact.5. Technology & DataPartner with IT and data organizations to modernize CM/UM platforms and supporting data ecosystems.Define requirements for workflow, clinical decision support, interoperability, analytics, and reporting.Support integration with EHRs, payer platforms, provider systems, CRM, care management platforms, and data platforms.Evaluate and implement AI/agentic capabilities for clinical workflows, authorization, documentation, and care management.6. Multi-State OperationsDevelop a common enterprise CM/UM framework while maintaining flexibility for state-specific requirements.Coordinate implementation across multiple health plans, markets, Medicaid programs, and regulatory environments.Establish reusable processes, technology components, data models, and implementation playbooks.