Director of Utilization Management (UM) Operations
# Director of Utilization Management (UM) Operations **Calibrated healthcare** · Ontario, CA 91764 · `On-site` 🕒 **Статус:** *Опубликовано: вчера* · *Источник: Indeed* --- ### About the Role Company Information: Calibrated Healthcare is a Business Process Outsourcing (BPO) organization providing healthcare administrative and medical management support services to clients throughout the healthcare industry. Headquartered in Ontario, California, Calibrated Healthcare has operations in the United States, India, and the Philippines. Position Overview: The Director of Utilization Management Operations is responsible for the overall leadership, performance, and operational effectiveness of Calibrated Healthcare's onshore and offshore UM Department. The Director will oversee both UM Coordinator and clinical UM operations, including UM Coordinators, nurses, supervisors, managers, and other operational staff supporting multiple healthcare clients. This position is responsible for ensuring UM operations consistently achieve client expectations and established requirements for quality, productivity, turnaround times, regulatory compliance, service levels, and overall operational performance. The successful candidate must be an exceptional people leader who can develop strong teams and managers, establish accountability, recognize operational issues early, resolve escalations, and maintain strong relationships with clients and internal leadership. This position requires a leader who is equally comfortable managing people, operations, clients, and performance. Licensure/Certification: · Active and unrestricted California Registered Nurse (RN) license. Responsibilities: · Provide overall leadership and operational oversight for onshore and offshore Utilization Management operations, including teams located in the United States, India, and the Philippines. · Lead and support UM Coordinators, clinical UM nurses, supervisors, managers, and other UM operational staff. · Oversee day-to-day UM operations across multiple client accounts and ensure consistent execution of client-specific workflows, policies, procedures, and service requirements. · Establish clear expectations and accountability for quality, productivity, accuracy, turnaround times, attendance, inventory management, and SLA performance. · Monitor operational dashboards, production reports, quality results, inventory, aging, staffing levels, and other key performance indicators. · Ensure appropriate staffing and coverage based on client volumes, workload, service requirements, and operational priorities. · Identify operational and performance issues early and implement timely corrective actions, coaching, training, workflow improvements, or staffing adjustments. · Develop supervisors, managers, and team leads to effectively manage their teams, resolve issues, and maintain operational performance. · Provide coaching, feedback, performance management, and professional development to UM leadership and staff. · Build and maintain a culture of accountability, collaboration, communication, quality, and continuous improvement across all UM teams. · Responsible for training, performance management, and employee development. · Provide leadership during new client implementations, operational transitions, new process launches, and expansion of existing UM services. · Evaluate workflows and implement process improvements to increase operational efficiency, quality, and consistency. · Ensure appropriate escalation processes are established and followed for operational, clinical, client, and regulatory issues. · Provide operational leadership for both administrative and clinical Utilization Management functions. · Maintain a strong understanding of managed care authorization workflows, including inpatient, outpatient, routine, urgent, expedited, retrospective, and clinical review processes. · Ensure UM Coordinators and clinical staff understand and consistently follow established authorization workflows and escalation requirements. · Collaborate with Medical Directors and clinical leadership regarding clinical review processes, escalation pathways, and operational requirements. · Ensure appropriate application of client-specific guidelines, policies, procedures, and clinical criteria. · Support effective coordination between UM Coordinators, nurses, Medical Directors, Eligibility, Claims, Provider Relations, Customer Service, and other operational departments as required. · Develop and maintain strong working relationships with clients and serve as a senior operational point of contact for UM services. · Participate in client meetings, operational reviews, performance discussions, and escalation meetings. · Understand client expectations, contractual requirements, workflows, and service-level commitments. · Provide clear and timely communication regarding operational performance, risks, staffing, quality, and corrective actions. · Develop and implement corrective action plans when operational, quality, compliance, or SLA expectations are not achieved. · Work collaboratively with clients to identify opportunities for process improvement and operational efficiencies. · Support client implementations and transitions by ensuring staffing, training, workflows, reporting, and operational readiness are completed appropriately. · Ensure UM operations comply with applicable CMS, DMHC, health plan, delegated entity, and client-specific requirements, including required turnaround times. · Maintain a strong understanding of regulatory and health plan requirements applicable to Utilization Management operations. · Ensure established quality standards are consistently achieved across all UM teams. · Monitor quality trends and work with Quality and Training teams to address identified performance gaps. · Support health plan audits, delegation oversight activities, regulatory reviews, and corrective action plans. · Ensure policies, procedures, workflows, and operational practices remain aligned with client and regulatory requirements. · Promote an environment in which quality and compliance are treated as operational responsibilities at every level of the organization. Experience Requirements: · Active and unrestricted California Registered Nurse (RN) license. · Significant leadership experience in Utilization Management within a managed healthcare environment. · Prior leadership experience within an IPA, MSO, health plan, delegated medical group, or healthcare services organization strongly preferred. · Strong working knowledge of managed care Utilization Management operations, including both administrative and clinical UM functions. · Demonstrated experience managing UM Coordinators and clinical UM nurses. · Strong understanding of authorization workflows and clinical review processes. · Working knowledge of CMS and DMHC Utilization Management requirements, regulatory turnaround times, and delegated health plan requirements. · Demonstrated experience managing operational productivity, quality, inventory, staffing, SLAs, and performance metrics. · Experience leading managers, supervisors, and geographically dispersed operational teams. · Exceptional people-management skills with demonstrated ability to coach, develop, motivate, and hold teams accountable. · Strong problem-solving and analytical skills with the ability to identify root causes and implement sustainable operational solutions. · Excellent verbal and written communication skills. · Strong client-facing and relationship-management skills. · Ability to manage multiple clients, priorities, deadlines, and operational requirements in a fast-paced environment. · Strong organizational, decision-making, and leadership skills. · High degree of professionalism, integrity, judgment, and accountability. · Proficiency with Microsoft Office and the ability to work effectively within highly computerized healthcare environments. Preferred Qualifications: · Experience managing offshore or global healthcare operations, particularly teams located in India and/or the Philippines. · Experience working within a healthcare BPO or multi-client managed services environment. · Experience with delegated Utilization Management operations and health plan oversight. · Experience supporting health plan and regulatory audits. · Experience with healthcare UM systems and managed care technology platforms. · Experience with operational implementations, transitions, and project management. · Experience building, restructuring, or scaling UM teams and operations. Work Location Primary office location: Ontario, California Pay: $150,000.00 - $175,000.00 per year Benefits: 401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance Work Location: Hybrid remote in Ontario, CA 91764
Наблюдалась 2026-09-23, впервые 2026-09-21, источник — Indeed.