Manager, Case Management
ConcertoCare
Utilization Management RN, Payer Operations
Humata Health
full-time
Posted on:
Origin: • 🇺🇸 United States • Florida
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Partner with health plan utilization review nurses to validate and improve AI-driven prior authorization workflows
- Review and structure medical policies to enable AI-powered automation of utilization review decisions
- Apply clinical judgment to ensure that AI outputs align with evidence-based guidelines, payer standards, and medical coding practices
- Participate in product review cycles by providing feedback on usability, accuracy, and workflow alignment
- Guide product teams by translating clinical and utilization review needs into actionable product requirements
- Collaborate with product and engineering teams to refine how clinical decision points are represented in AI models
- Test, validate, and continuously improve AI-enabled review tools for accuracy and fairness
- Provide feedback to enhance both policy digitization workflows and AI-driven decision support
- Manage small-scale projects, including organizing digitization initiatives, tracking timelines, coordinating stakeholders, and reporting on progress
- Stay current on payer requirements, clinical guidelines, regulatory standards, and coding updates relevant to utilization management
Requirements
- Registered Nurse (RN) with an active license
- 3+ years of experience in utilization management, prior authorization, case management, or related clinical roles
- Strong understanding of payer policies, medical necessity criteria, and the prior authorization process
- Working knowledge of medical coding systems (ICD-10, CPT, HCPCS)
- Comfort working with technology platforms; interest or experience in AI, clinical decision support, or health tech is a plus
- Demonstrated project management skills — ability to organize complex workflows, manage deliverables, and ensure accountability across teams
- Excellent critical thinking and problem-solving skills
- Strong communication and collaboration abilities across clinical and technical teams
- Preferred: Certification in medical coding (e.g., CPC, CCS, CCA, or equivalent)
- Preferred: Experience reviewing or implementing medical policies in a payer or managed care setting
- Preferred: Familiarity with health informatics, evidence-based guideline development, or digital clinical tools
- Preferred: Background in leading cross-functional projects or initiatives (formal project management certification is a plus)
- Preferred: Experience working with AI, automation tools, or clinical decision support systems
- Preferred: Ability to work in a fast-paced, innovative environment and contribute to process improvement
- Must be legally authorized to work in the United States (application form asks)
