Utilization Management Manager

About IntusCare: IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. We empower teams to take control of their operations and improve outcomes for dual-eligible seniors- some of the most socially vulnerable and clinically complex individuals in the US healthcare system. Position Overview: The Utilization Management (UM) Manager is fully accountable for the performance of the UM nurse team supporting a Program of All-Inclusive Care for the Elderly (PACE). This role owns end-to-end delivery of the UM program, including meeting all service-level agreements (SLAs), ensuring consistent application of policies, procedures, and clinical decision support criteria, and driving continuous improvement across the UM function. The UM Manager spends approximately 25% of their time working directly on UM cases and provider disputes—maintaining clinical currency, modeling best practices, and handling escalated or complex reviews—and the remaining 75% managing team performance, service quality, staffing, coaching, and cross-functional coordination. The role partners closely with the IntusCare Utilization Management clients, the IntusCare Director of Clinical Operations and the Contracted Physician to assure high quality service and customer service. KEY RESPONSIBILITIES TEAM LEADERSHIP & PERFORMANCE MANAGEMENT (APPROXIMATELY 75% OF TIME) • Hold full accountability for UM team performance, including meeting or exceeding all program SLAs (turnaround times, decision timeliness, dispute resolution timelines, documentation completeness, and quality benchmarks). • Establish, monitor, and report on individual and team performance metrics; conduct regular one-on-ones, performance reviews, and coaching sessions to drive accountability and professional growth. • Ensure consistent application of PACE service authorization policies, standard operating procedures, and clinical decision support criteria (e.g., MCG) across every reviewer and every case. • Design and lead ongoing quality assurance (QA) and inter-rater reliability activities; identify variance in decision-making, address it through targeted coaching or process changes, and document outcomes. • Manage staffing, scheduling, workload distribution, and case assignment to ensure sustained SLA performance during volume fluctuations, coverage gaps, and PTO. Perform case reviews as needed during staff PTO to assure timely case completion and accuracy. • Recruit, onboard, and develop UM nurses; build competency-based training programs and structured ramp plans for new hires. • Foster a culture of accountability, collaboration, psychological safety, and continuous improvement. • Maintain and update UM policies, procedures, workflows, and job aids; ensure changes are communicated, trained on, and audited for adoption. • Partner with the contracted IntusCare Contracted Physician to define escalation pathways and ensure clinical decision-making support is available when needed. • Use data analytics to monitor care patterns, cost drivers, length-of-stay trends, denial and overturn rates, and utilization efficiency; translate findings into targeted improvement initiatives. • Lead or sponsor rapid-cycle performance improvement initiatives across UM functions. • Prepare and present program performance reporting to internal leadership and PACE client stakeholders. DIRECT UM CASE & DISPUTE WORK (APPROXIMATELY 25% OF TIME) • Personally handle a defined caseload of UM reviews and provider disputes to remain clinically current, model expected practice, and manage escalations. This includes: ◦ Initial and Concurrent review of hospital admissions (observation and inpatient) with the…