Senior Manager, Utilization Management

This position is responsible for providing oversight to the daily functions of the Utilization Management (UM) for the Medicaid and the Medicare beneficiaries. The Senior Manager of UM will assist and partner with the Director of Health Services, Vice President of Health Services and the Medical Directors in implementing the culture and work environment that promotes and inspires an active continuous improvement philosophy in regard to overseeing medical and utilization control program that safeguards against unnecessary or inappropriate use of services. The Senior Manager will have oversight for UM Managers and staff in all VPHP regions. Additional responsibilities include coordinating, conducting and documenting simple to complex Health Services projects and operational procedures and identification of process for utilization management.

Medical Management
Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals

• In collaboration with the Director of UM, provides clinical and operational oversight of each Health Services initiative which includes utilization management and the analysis of clinical data to drive performance improvement.
• Oversees the functions of UM and other support staff according to VPHP’s policy and procedures to assure that UR reviews and activities are accurate, consistent, and performed in a timely manner.
• Assists with the review and revision of UM Program Descriptions annually or as indicated by contract or accreditation requirements.
• Conducts annual evaluation of UM programs per contract or regulatory requirements.
• Monitors the efficiency and effectiveness of the Plan’s Utilization activities through analysis and the use of relevant data and management reports.
• Supervises and mentors UM Managers and Supervisors throughout the state; serve as a resource regarding issues and initiatives related to Utilization Review.
• Identifies, assesses, develops, and implements cross-functional, cross-departmental work processes that impact various departments or the company to improve clinical outcomes.
• Collects, reports, trends, and analyzes UM program elements for departmental productivity and performance outcome reporting.
• Serves in an advisory capacity for problem solving, reviewing reports being sent to internal and external customers, reviewing problematic cases, and monitor UM activities.
• Administer the inter-rater reliability exam at least yearly or as needed to UM staff and monitor for consistency.
• Validates UM quality audit results for accuracy and individual developmental needs.
• Develops staff performance objectives based on identified improvement or developmental opportunities and aligns with organizational performance outcome objectives.
• Review specialized reports to identify trends and opportunities for improvement to enhance relationships with the provider network and service to members.
• Develops, implements, and monitors policies and procedures for contract and accreditation compliance.
• Assists in the ongoing development of programs and medical management projects to enhance/expand the medical management department.

• Current, unrestricted RN license in the Commonwealth of Virginia
• Bachelors of Science required, Masters preferred; years of applicable work experience considered.

• Highly motivated individual with the ability to work independently as well as part of a team
• Excellent verbal and written communication skills
• Knowledge of NCQA and HEDIS
• Knowledge of evidence based criteria, such as InterQual
• Ability to build and support successful work teams
• Strong analytical problem-solving, time management, and organizational skills
• Knowledge of Six Sigma Lean methodology or other Performance Improvement methodology
• Proficient Microsoft Office product computer skills

• Minimum of five (5) years of clinical nursing experience
• Utilization Management experience
• Minimum of five (5) years of management experience in a managed care environment
• Knowledge of medical terminology

• Physical health sufficient to meet the ergonomic standards and demands of the position


Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs. Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia.

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

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