Supervisor, Utilization Management

Job Description

Job Description

The Clinical Utilization Management (UM) Supervisor is responsible for overseeing daily operations of the Utilization Management team to ensure timely, accurate, and appropriate clinical decision-making and case management. This role provides leadership, coaching, and clinical oversight to UM staff including nurses and support personnel, ensuring compliance with regulatory requirements, accreditation standards, and organizational policies.

Essential Functions / Key Responsibilities :

• Supervise daily activities of the UM team, including nurses and administrative support staff.
• Ensure timely and accurate medical necessity reviews for inpatient, outpatient, and other healthcare services according to internal protocols and regulatory guidelines.
• Monitor workloads, productivity, and performance metrics to ensure team efficiency and effectiveness.
• Provide clinical oversight and guidance on complex cases and escalate when needed.
• Ensure adherence to federal and state regulations, NCQA / URAC standards, and payer requirements.
• Collaborate with medical directors, providers, and case management staff to coordinate appropriate care and avoid unnecessary utilization.
• Participate in audits, reporting, and performance improvement initiatives.
• Train, mentor, and evaluate staff performance; participate in hiring and disciplinary processes.
• Develop and implement standard operating procedures (SOPs) for UM functions.
• Stay updated on changes in healthcare regulations, utilization trends, and evidence-based clinical guidelines.

Competencies :

Required education and experience :

Preferred education, certifications and / or experience :

Physical Requirements / Work environment :