LOB DESCRIPTION: Utilization Management - medical necessity approval/ denials for pre-service, retrospective, and concurrent services.

JOB SUMMARY:

The Operations Manager for Utilization Management is responsible for managing and overseeing UM operations, ensuring compliance with industry standards and regulatory requirements. The role involves close collaboration with various stakeholders to drive performance and maintain high-quality standards.

QUALIFICATIONS:

• Bachelor’s Degree in Nursing with an active and valid license in USRN
• Must have at least 1 or 2 years in a managerial role handling leaders/ TLs/ Supervisors
• Experience in managing teams handling Utilization Management and clinical denials.
• Experience in handling appeals denials, utilization review, or related healthcare management functions
• Well-versed in Medical Guidelines (e.g MCG, InterQual, NCQA, ODG)
• Excellent verbal and written communication skills
• Willingness to work on-site with flexible schedules, including US hours and holidays
• Must not be a current or former employee of Concentrix

KEY RESPONSIBILITIES:

• Oversee daily operations and ensure compliance with SLAs and regulatory standards.
• Developer and implement process improvement initiatives.
• Manage team performance and resource allocation,
• Collaborate with internal and client stakeholders to enhance service delivery and maintain accurate staffing.
• Ensure adherence to HIPAA and other regulatory requirements.