Manager, Health Plan Utilization Management – RN

Sanford Health

Manager of Health Plan Utilization Management overseeing nursing department operations. Responsible for quality improvement and compliance with healthcare guidelines in diverse member populations.

Posted 5/2/2026full-timeSioux Falls • South Dakota, Wisconsin • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Oversee health plan utilization management department operations including prior authorization, and concurrent review focusing on improving care quality and outcomes across a diverse member population while ensuring compliance with CMS, NCQA, and state/federal guidelines.
Responsible for the day to day oversight of department function both in terms of provision of service and providing direct supervision of all departmental staff.
Maintains a standardization of utilization management process to ensure all policies and procedures are followed effectively and efficiently.
Considered an expert resource with the centers for Medicare and Medicaid services (CMS).
Coordinates authorization/certification of care for designated populations to establish medical necessity and ensure maximum reimbursement while maintaining a high level of customer satisfaction.
Actively involved in reviewing information submitted by internal or external referral sources regarding a variety of cases which have the potential to develop into complex and/or costly scenarios and assisting the finance department in understanding the financial implications of these conditions.
Management of medical denials, appeals, and grievances.
Understand and provide insight into evaluating current process improvement strategies including quality, methods, and ability to maintain focus on the continuous improvement of processes, products and services.
Manage processes to support attainment of goals within department and organization.
Knowledgeable of industry standards, governing bodies, and regulations.
Adjusts to new or changing assignments, processes, and people.
Being a positive role model for staff to coach, educate and support both the employees and organizational growth.
Determines individual and team competency requirements, vulnerabilities, and learning needs.
Assumes management responsibilities such as payroll, scheduling, day-to-day staffing and crucial conversations in collaboration with human resources and leadership.
Identifies opportunity for personal and professional growth and pursues educational opportunities.

Requirements

What you’ll need

Bachelor's degree in nursing required
Master's degree in nursing preferred
Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA)
Four years of clinical nursing experience required
Two years experience as a case manager preferred
One year of leadership/management experience preferred
Experience in medical necessity review preferred
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state
Obtains and subsequently maintains required department specific competencies and certifications.
Certification is encouraged and may be required depending on specialty or service area.

Benefits

Comp & perks

Health insurance
Retirement plans
Paid time off
Professional development opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical nursing experiencecase managementmedical necessity reviewutilization managementprocess improvementquality assurancestaff supervisiondenial managementappeals managementgrievance management

Soft Skills

leadershipcoachingcommunicationorganizational growthteam competency assessmentadaptabilitycustomer satisfaction focusproblem-solvingeducational supportrole modeling

Certifications

Bachelor's degree in nursingMaster's degree in nursingunencumbered registered nurse (RN) licensemultistate licensure (NLC)department specific certifications