Utilization Review Coordinator remote jobs

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Manager, Utilization Management (UM) Coordination, oversees non-clinical inpatient and pre-service operations under the direction of the Director of Utilization Management. This role provides leadership to UM Supervisors and their coordinator teams to ensure timely, accurate, and compliant processing of authorizations and referrals in accordance with CMS and organizational standards. The Manager drives operational efficiency, staff development, and process improvement while collaborating with internal departments to support continuity of care and overall service quality. Job Responsibilities: Provide operational leadership and direction to two Utilization Management Supervisors overseeing non-clinical coordinator teams supporting both Inpatient and Pre-Service workflows. Lead the teams meet established turnaround times (TATs), quality, and productivity standards for authorization processing, referral routing, and related UM functions. Oversee staffing allocation, scheduling, and workload balancing between inpatient and pre-service units to maintain consistent service levels. Conduct regular one-on-one meetings with supervisors to review performance metrics, workflow barriers, and staff development needs. Own the daily operations to ensure timely and accurate completion of authorizations, correspondence, and documentation in compliance with CMS, NCQA, and organizational standards. Identify process inefficiencies and implement corrective actions to improve turnaround, accuracy, and staff productivity. Lead root-cause analyses for escalated operational issues and coordinate corrective action plans. Responsible for all the accuracy of all UM workflows, systems, and reporting dashboards to support data-driven decision making. Oversee the development and delivery of training materials, competency assessments, and reference guides to promote consistent and compliant practices. Mentor Supervisors to build leadership capacity, coaching them on staff management, delegation, and performance improvement techniques. Drive onboarding, cross-training, and refresher sessions are regularly conducted to support staff versatility across inpatient and pre-service functions. Manage all team activities adhere to CMS and organizational policies related to Utilization Management, confidentiality, and member communication standards. Oversee internal audit reviews and collaborate with the Quality and Compliance teams to address findings and implement improvement plans. Direct that all letters and communications use approved templates and standardized language for UM determinations and continuity-of-care requirements. Participate in internal and external audits, Medical Services Committee meetings, and other regulatory reviews as required. Review and analyze key performance indicators (KPIs), including volume, turnaround time, accuracy, and productivity reports; present trends and improvement strategies to leadership. Support the preparation and submission of monthly UM reports, dashboard summaries, and Medical Services Committee deliverables. Leverage data to identify training needs, process gaps, and operational trends impacting service delivery or compliance. Serve as a liaison between UM, Case Management, Provider Relations, and Claims departments to streamline interdepartmental communication and issue resolution. Collaborate with network providers and internal teams to clarify authorization processes and ensure alignment with benefit and policy criteria. Participate in internal workgroups or initiatives to improve system functionality, workflow automation, and reporting enhancements. Assist with the development, implementation, and monitoring of UM-related initiatives and special projects (e.g., claims review process, continuity-of-care tracking, or performance optimization programs). Evaluate and revise UM policies and procedures to align with evolving regulatory standards and organizational goals. Support readiness activities for CMS audits and other accreditation requirements. Perform other related functions and special assignments as directed by senior leadership. Core Competencies: Leadership & Talent Development - Demonstrates the ability to lead through others by developing and empowering supervisors and staff. Fosters a culture of accountability, engagement, and continuous improvement within the UM department. Operational Management - Applies strong organizational and analytical skills to oversee workflow execution, resource allocation, and performance metrics across inpatient and pre-service teams. Regulatory & Compliance Expertise - Maintains in-depth knowledge of CMS regulatory standards, confidentiality requirements, and UM protocols to ensure full compliance and audit readiness. Analytical Thinking & Decision-Making - Uses data to identify trends, evaluate outcomes, and implement process improvements that enhance accuracy, turnaround times, and service quality. Communication & Collaboration - Communicates clearly across all organizational levels; partners effectively with Clinical Operations, Provider Relations, Case Management, and Claims to resolve issues and align priorities. Process Improvement & Innovation - Continuously evaluates operational workflows and implements efficiency strategies that support organizational goals and member satisfaction. Member & Service Orientation - Demonstrates commitment to delivering high-quality service, ensuring that UM processes support positive member experiences and continuity of care. Change Management - Adapts to evolving regulatory, system, and organizational needs while leading teams through process transitions and new initiatives effectively. Supervisory Responsibilities: Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance management. Job Requirements: Experience Required: Minimum (4) years of related experience in a managed care setting and a minimum (3) years of recent and related supervisory experience Education Required: Highschool Diploma or GED Required Preferred: Bachelor's Degree or higher Other: Strong knowledge of Medicare Managed Care Plans Proficient in Microsoft Word, Excel, and Outlook; advanced Excel skills preferred (pivot tables, formulas, data visualization, and reporting functions for performance tracking and analysis). Experience leading and sustaining process improvement initiatives within healthcare operations to enhance efficiency, compliance, and service quality. Communication and Interpersonal Skills - Excellent written and verbal communication skills; able to build and maintain collaborative relationships with diverse teams, including leadership, staff, and external partners. Analytical and Reasoning Skills - Strong analytical thinking with the ability to define problems, collect and interpret data, establish facts, draw valid conclusions, and develop actionable solutions. Problem-Solving and Organizational Skills - Demonstrated ability to prioritize multiple tasks, manage time effectively, and maintain accuracy in a fast-paced, dynamic environment. Data and Report Analysis - Ability to interpret, analyze, and present statistical and operational reports to support decision-making and performance monitoring. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Pay Range: $70,823.00 - $106,234.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. *DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at ******************************* If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email ******************.