Directs the utilization review clinical team operations for our Commercial plans
Provide decisive leadership and direct supervision to a clinical staff team, including subordinate leaders and their teams.
Execute a forward-thinking utilization management strategy that aligns with the company's goals.
Lead performance management, including hiring, professional development, mentorship, and performance evaluations to build a high-performing, engaged team.
Foster a culture of clinical excellence, empathy, and member-centered care.
Direct all utilization review functions, including pre-service, concurrent, and retrospective reviews, ensuring timeliness and adherence to evidence-based medical necessity criteria and internal medical policies.
Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.

A bachelor’s degree in nursing or related clinical field is required
A master’s degree in healthcare administration, Public Health, Nursing, or a related clinical field is strongly preferred
Must possess an active, unrestricted clinical license in Nursing or related clinical field (e.g., RN, NP, PA, etc.)
Must have the ability to secure equivalent licensure within the State of Massachusetts within 6 months of hire date
A minimum of 5-7 years of professional experience and progressive leadership in utilization management within a health plan or health system setting preferred.
Proven experience overseeing utilization review in a managed care organization is highly desirable.

Senior Manager, Clinical Review

Key skills