Supervisor, Utilization Management (Hybrid Remote, Must have California LVN / RN License)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Supervisor, Utilization Management, under the direction of the Manager of UM, is responsible for ongoing management of the UM Department and oversight of preservice processes. Directly supervise licensed and coordinator staff performing UM duties. Accountable for promoting quality patient care outcomes while supporting appropriate resource management along the continuum of care and responsible for auditing and completing reports to meet CMS compliance requirements. Please note: This is an exempt leadership role supporting a clinical team that operates Monday–Friday during Pacific Time business hours. The supervisor is expected to maintain regular availability during these hours to provide leadership oversight, support clinical operations, and partner with interdisciplinary teams. Weekend leadership coverage is shared between the supervisor and director on a rotating basis to provide availability for staff support and escalations. This position is primarily remote; however, in-person attendance at Alignment Health’s headquarters in Orange, CA is required approximately once per quarter for leadership meetings and team collaboration. Candidates located outside of California should expect periodic travel to the Orange office. Travel expenses are reimbursed in accordance with company policy.

Ensure UM clinical staff members perform Pre-Service reviews on submitted requests within CMS and Alignment Health turnaround timeframes and according to regulatory and Health Plan guidelines. Ensure staff use sound clinical judgment to make final determinations, utilizing Alignment Health approved clinical criteria according to hierarchy. Ensure staff follow pre-service workflows. Ensure staff put the member first while managing benefits appropriately, considering the individual’s unique needs. Ensure assigned staff comply with CMS and Alignment Health interdepartmental processes when participating in the Medical Claims Review process. Ensure staff coordinate care internally and externally. Monitor documentation to ensure alignment with Health Plan and department policies, protocols, and standard operating procedures. Collect, evaluate, and report data and activities as applicable within the UM program (e.g., monthly, quarterly, and annual reports). Perform department quality and vendor audits to assess case timeliness and ensure compliance. Collaborate with primary care physicians, specialty care physicians, mental health professionals, home health professionals, and other healthcare professionals regarding escalated needs. Establish and maintain effective interpersonal relationships with staff at all levels, providers, and internal departments. Attend meetings with vendors and/or other departments regarding UM policies and procedures. Maintain confidentiality of information between and among healthcare professionals. Perform UM reviews when required, including handling escalated cases. Implement Alignment internal and CMS-specific programs (e.g., Medical Claims Review). Develop, review, and revise as necessary policies, procedures, protocols, and processes related to Pre-Service and Claims UM. Other duties as requested or assigned. SUPERVISORY RESPONSIBILITIES: Oversee assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees. Recruit, select, onboard, train, mentor, and coach UM clinicians and coordinators to ensure compliance with internal and regulatory guidelines. Assign workload; plan, monitor, and appraise work results. Conduct 1:1 coaching (coach, counsel, and discipline) with employees and create, implement, and track corrective action plans and Objectives and Key Results (OKRs). Manage time-off requests, scheduling, and overtime utilization. Create and maintain an environment that inspires and encourages the growth and engagement of team members.