The Utilization Management Manager is responsible for leading a team of clinical reviewers to ensure high-quality service, adherence to SLAs, and consistent application of clinical policies. The role balances team performance management with direct clinical case reviews, provider dispute resolution, and cross-functional collaboration with PACE programs.
The Utilization Management Nurse ensures high-quality, cost-effective, and compliant care by reviewing service utilization and guiding care decisions within PACE programs. They also manage the provider appeals process and collaborate with interdisciplinary teams to facilitate efficient transitions of care.
The Director of SRE will own the reliability, availability, and operational excellence of the product portfolio while leading a blended team of SRE and QA professionals. They will define the SRE strategy, establish SLA/SLO frameworks, and oversee incident management and release engineering processes.
The role involves reviewing service utilization and managing transitions of care for PACE participants to ensure medical necessity and compliance. It also includes leading the provider appeals process and collaborating with Medical Directors to issue written determinations.
Own the commercial tech stack and CRM administration to ensure data quality and operational efficiency. Develop pipeline reporting, forecasting models, and scalable sales processes to drive predictable revenue growth.
Perform State Encounter coding activities by applying CPT and E & M codes according to AMA standards. Ensure all coding is accurately supported by clinical documentation and adheres to internal quality guidelines.
The Senior Product Manager will lead the strategy and execution for the risk adjustment product, partnering with design and engineering to shape the next generation of the platform. This involves engaging directly with clients to uncover needs and collaborating across departments to ensure products meet market demands and regulatory requirements.
