Manager, Utilization Management
Southeast Medical Group
full-time
Posted on:
Location Type: Hybrid
Location: Alpharetta • United States
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About the role
- Monitor, evaluate, and optimize healthcare utilization across a network of independent provider practices
- Identify utilization trends, uncover drivers of high spend, and implement actionable strategies in collaboration with clinicians, patients, and senior leadership
- Conduct reviews for medical necessity and the utilization of ancillary services to ensure the appropriate level of patient care
- Collaborate with Analytics Team to leverage claims data, population health reports, and EMR data
- Develop and lead a strong UM team to support multiple payers, ACOs, and physician practices
- Conduct targeted outreach to share actionable, data-driven insights; highlight opportunities to reduce unnecessary utilization
- Identify high-risk, high-cost patients using claims and analytics tools
- Partner closely with the Medical Director to review complex cases and utilization patterns
- Track and report on utilization trends, interventions, and outcomes.
Requirements
- 3–5+ years of experience in Utilization Management, Care Management, or a related field
- Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related field
- Clinical background (currently licensed LPN, RN, or equivalent)
- Experience in payer, hospital/health system, or ACO environment preferred
- Strong understanding of healthcare utilization drivers; claims data analysis; transitions of care; and care coordination.
- Preferred Certification (e.g., CCM, CPUR, or equivalent) is a plus.
- Experience in value-based care models (ACO, Medicare Advantage, Commercial) highly desirable.
Benefits
- Flexible work arrangements
- Opportunity to impact cost and quality outcomes
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
utilization managementclaims data analysiscare coordinationdata-driven insightsmedical necessity reviewspopulation health reportsancillary services utilizationhigh-risk patient identificationvalue-based care modelstransitions of care
Soft Skills
collaborationleadershipcommunicationanalytical thinkingproblem-solvingstrategic planninginterpersonal skillsoutreachteam developmentreporting
Certifications
CCMCPURLPNRN