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Job Description Utilization Management Director Healthcare is increasingly unaffordable for many Americans. For those who can afford it, they are in a health insurance system that has become more confusing, restrictive, and lower value with each passing year. Here at WeShare our mission is to bring better healthcare to America at a better price. We offer consumers a member-to-member health sharing program that is much more cost effective than standard health insurance while providing access to over 1.2 million physicians across the country. Come join us on this important journey to create the next generation of healthcare! WeShare is a rapidly growing faith-based nonprofit that strives to do good while delivering great and affordable healthcare. The company is led by senior executives with an extensive background in both for-profit and not-for-profit enterprises. If you have a bias for action, enjoy challenges, and love creating impact in a massive industry, WeShare might be the place for you! About this role The Utilization Management Director will be responsible for building and leading UHSM’s first internal clinical utilization management function. This role will establish the structure, processes, policies, and team supporting end-to-end utilization management and clinical review functions, including medical necessity determinations, prior authorization, concurrent and retrospective review, Shared Medical Bills (SMB) clinical review, appeals support, and associated provider and member communications. This is a foundational leadership role for the organization. The Director will partner closely with SMB, Provider Services, Member Services, Compliance, Operations, and executive leadership to establish a clinically sound, compliant, member-centered, and operationally efficient utilization management program. The ideal candidate is a licensed clinical professional with strong utilization management experience, payer or managed care knowledge, and the ability to build a department from the ground up. Key Responsibilities Department Buildout & Clinical Leadership • Develop and launch UHSM’s internal Utilization Management and Clinical Operations function, including workflows, policies, procedures, staffing models, documentation standards, and performance metrics., • Inform design and implementation of a Salesforce-based clinical case management platform, partnering with internal and technical teams to define requirements, configure workflows, and optimize utilization management operations., • Drive evaluation and selection of a clinical guideline engine (medical necessity criteria tool) and oversee integration with the case management system to support prior authorization, concurrent, and retrospective review workflows., • Establish clinical review processes for prior authorization, pre-service review, concurrent review, retrospective review, medical necessity review, and SMB-related clinical evaluation and underwriting., • Build and lead a clinical team, which may include UM nurses, clinical reviewers, care coordinators, clinical operations specialists, and administrative support staff., • Create clear role definitions, training plans, quality review processes, and performance expectations for clinical team members., • Serve as the organization’s subject matter expert on utilization management, clinical review operations, and medical necessity processes. Utilization Management Program Oversight • Oversee the review of requested healthcare services to support appropriate, evidence-based, timely, and consistent determinations., • Ensure clinical reviews are based on relevant clinical documentation, plan/program guidelines, recognized clinical criteria, and applicable regulatory or accreditation standards., • Develop processes for urgent and non-urgent reviews, provider communication, additional information requests, peer review escalation, and documentation of determinations., • Monitor utilization trends, high-cost services, inpatient stays, readmissions, out-of-network utilization, gaps in care coordination, and other clinical cost drivers., • Partner with leadership to identify opportunities to improve clinical outcomes, reduce avoidable costs, and strengthen member/provider experience. Clinical Governance, Compliance & Quality • Develop policies and procedures aligned with appropriate utilization management standards, including medical necessity review, clinical criteria use, denial documentation, appeals support, and peer review escalation., • Partner with Compliance to ensure utilization management processes meet applicable federal, state, contractual, and organizational requirements., • Support audit readiness and maintain accurate documentation for clinical decisions, review rationale, notifications, appeal support, and quality monitoring., • Establish quality assurance processes to monitor clinical review accuracy, timeliness, consistency, and documentation quality., • Stay current on utilization management best practices, payer operations, healthcare regulations, and accreditation standards such as NCQA or URAC, as applicable. Cross-Functional Partnership • Collaborate with the SMB team to support clinical review of complex SMBs, high-dollar SMBs, disputed SMBs, coding-related clinical questions, and medical necessity concerns., • Partner with Provider Services to improve provider communication, documentation requests, prior authorization workflows, and provider education., • Partner with Member Services to ensure clinical review processes are clearly communicated, and member escalations are handled appropriately., • Work with executive leadership to define the long-term clinical team structure, including future roles such as Medical Director, UM Nurse, Case Manager, Clinical Appeals Nurse, or Care Management Manager., • Support vendor evaluation and management for clinical review tools, utilization management platforms, medical necessity criteria, peer review vendors, case management resources, or external clinical consultants. Metrics & Reporting • Develop dashboards and reporting for utilization management activity, turnaround times, approval/denial trends, appeal outcomes, inpatient days, high-cost services, reviewer productivity, quality audit results, and provider/member escalations., • Use data to identify process gaps, training needs, cost-containment opportunities, and clinical risk areas., • Present findings and recommendations to executive leadership in a clear, actionable manner. Minimum Qualifications • Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related clinical/healthcare field., • Active, unrestricted Registered Nurse license or other applicable clinical license required. Multistate Nurse Licensure Compact license preferred. Candidate must be eligible and willing to obtain additional state licensure if required based on organizational needs, member geography, applicable regulations, and assigned clinical responsibilities., • 7+ years of healthcare experience, including significant experience in utilization management, managed care, payer operations, clinical review, case management, or health plan operations., • 5+ years of leadership experience managing clinical staff, UM nurses, case managers, or healthcare operations teams., • Demonstrated experience managing departmental budgets, including headcount planning, vendor spend, and operational cost oversight, • Strong knowledge of utilization management functions, including prior authorization, medical necessity review, concurrent review, retrospective review, appeals support, and clinical documentation requirements., • Experience using evidence-based clinical criteria, such as MCG, InterQual, Medicare guidelines, plan guidelines, or similar review criteria., • Experience developing or improving clinical workflows, policies, procedures, training materials, and quality review processes., • Strong understanding of payer, TPA, managed care, health plan, or healthcare cost-containment operations., • Ability to build a department, lead change, influence cross-functional partners, and create structure in a developing environment., • Strong analytical skills with the ability to interpret utilization trends, claims data, clinical review data, and operational metrics., • Excellent communication skills, including the ability to explain clinical review decisions, process requirements, and policy recommendations to both clinical and non-clinical stakeholders. Preferred Qualifications • Master’s degree in Nursing, Healthcare Administration, Business Administration, Public Health, or a related field., • Experience building a utilization management, case management, clinical operations, or care management function from the ground up., • Prior experience in a health plan, managed care organization, TPA, self-funded employer plan, medical group, IPA, ACO, or healthcare sharing organization., • Experience with NCQA, URAC, CMS, ERISA, ACA, HIPAA, or state utilization management requirements, as applicable to the organization., • Certification such as CCM, ACM, CPHQ, CPUM, CPUR, CPMA, or similar healthcare quality/utilization/case management credential., • Experience working with Medical Directors, physician reviewers, peer-to-peer review processes, clinical appeals, and external review vendors., • Experience selecting or implementing UM platforms, clinical documentation systems, workflow tools, or medical necessity criteria systems., • Experience with budget ownership, P&L accountability, or financial stewardship within a clinical operations, health plan, or managed care environment., • Knowledge of claims operations, provider contracting, provider dispute resolution, coding, billing, or healthcare reimbursement. What we offer • Competitivesalaryand benefits package, including health, life dental, and vision insurance, 403(b) with company match, • The chance to make a meaningful impactinthe lives of individuals and familiesseekingaffordable, faith-based healthcare solutions, • Great culture where you work with the founders and key stakeholders in a relaxed, but innovative atmosphere UHSM is an Equal Opportunity Employer. Our business is fast-paced and will continue to evolve. As such, the duties and responsibilities of this role may be changed as directed by the Company at any time to promote and support our business needs. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, protected veteran status, or any other basis protected by applicable law and will not be discriminated against on the basis of disability.

We are looking to hire an Endocrine Nurse Practitioner or Physician Assistant to provide services to our patients through our HIPAA-compliant telemedicine platform.

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Physician Assistant / Nurse Practitioner to join our team. Ideal Physician Assistant / Nurse Practitioner candidates shall be diligent, hard-working individuals with an interest in Primary Care.

The CHOC Specialist physicians are committed to providing superior care to our patients and families. PSF includes more than 500 physicians and advanced practice providers across 26 pediatric subspecialties. Rady Children's Health and CHOC Specialists invite passionate physicians to join our team in

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Work with the physicians/surgeons/APP colleagues and other clinical and administrative staff to ensure efficient patient management based on accepted practice, including but not limited to, performing histories and physicals, pre-operative planning/coordinating with anesthesia/outside providers and

Supervising Physician may required depending on the state requirement.

Collaborate with physicians and other healthcare providers to ensure coordinated care.

Diagnosing and treating various health issues, both chronic and acute, through collaboration with physicians or independently as per your qualifications.

With skilled physicians in virtually every specialty, St. Its 122,000-plus caregivers/employees (including 34,000 physicians) serve in 51 hospitals, more than 1,000 clinics and a comprehensive range of health and social services.

PSF includes more than 500 physicians and advanced practice providers across 26 pediatric subspecialties. GI physicians, dietitians, and pharmacists. CHOC Specialists physicians and advanced practice providers are deeply committed to delivering compassionate, high-quality, family-centered care.

Locums - Nurse Practitioner - Nurse Practitioner-NP - Irvine - California.Opportunity: Gastroenterology Nurse Practitioner - Integrative Health.Work Monday through Friday, 8:00 AM to 5:00 PM (40 hours per week).Handle patient intake, perform histories, and assist with prescriptions, evaluations, ref

Diagnose and treat acute, episodic, or chronic disorders in collaboration with attending physicians or independently as permitted.

Assume responsibility for independent, direct medical management of a defined patient population, according to standardized procedures and in collaboration with a physician advisor or supervising physician. Maintain open lines of communication with the physician and multidisciplinary health team reg

Diagnosing and managing acute, chronic, or episodic health concerns, either independently or in cooperation with supervising physicians as required.

Cardiovascular Nurse Practitioner.The position will work in collaboration with the medical director of cardiothoracic surgery and hospital staff to provide comprehensive care including medical procedures that may be required for a specialty area, utilizing approved standardized procedures as outline

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Physician Assistant: Medical/Master's degree with a valid state license and national certification.

We are a fast-growing Private Practice and we are looking to add another Nurse Practitioner or Physician Assistant to our amazing team. We are looking for a Full Time or Part-Time Nurse Practitioner or Physician Assistant that can assist us in maintaining this high standard of care.

Nurse Practitioner or Physician Assistant position in the Division of Medical Oncology supporting our survivorship programs. Under general supervision and in accordance with standardized procedures, the nurse practitioner/physician assistant performs physical examinations and treats common episodi

The NP is accountable to, evaluated, and provided feedback by the supervising/collaborating physician, physician designee(s) in the same clinical specialty, or the Administrative Manager. Follows up with the General Surgery teams/residents/attending physicians. Under the joint supervision of Chief o

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Aesthetic Nurse Practitioner or Physician Assistant Newport Beach California Job#16647685. We are seeking a full-time experienced Aesthetic Nurse Practitioner or Physician Assistant to join our practice in beautiful Newport Beach California. Must have a valid Nurse Practitioner or Physician Assistan

Diagnosing and managing acute, chronic, or episodic illnesses alongside physicians or autonomously (as permitted by credentials).

The NP is accountable to, evaluated, and provided feedback by the supervising/collaborating physician, physician designee(s) in the same clinical specialty, or the Administrative Manager. Under the supervision of Anuj Ohri, MD and guided by the applicable policies and procedures, the Nurse Practitio

Providing diagnosis and management for acute, chronic, or episodic conditions in collaboration with physicians or autonomously (depending on licensure).

Assume responsibility for independent, direct medical management of a defined patient population, according to standardized procedures and in collaboration with a physician advisor or supervising physician. Maintain open lines of communication with the physician and multidisciplinary health team reg

Under the supervision of Anuj Ohri, MD and guided by the applicable policies and procedures, the Nurse Practitioner will participate in the comprehensive care of patients in the ambulatory or inpatient settings and provide multi-disciplinary care coordination, treatment, education, monitoring, and c

Diagnosing and managing acute, episodic, or chronic health conditions, either independently or alongside physicians, based on your credentials.

Locums - UCI Health Susan Samueli Integrative Health Institute.Locums - Nurse Practitioner - Nurse Practitioner-NP - Irvine - California.Gastroenterology Nurse Practitioner - Integrative Health.Work Monday through Friday, 8:00 AM to 5:00 PM (40 hours per week).Handle patient intake, perform historie

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If you are as passionate about helping those in need as you are about growing your career, consider AltaMed.At AltaMed, your passion for helping others isn't just welcomed – it's nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference.We don't just serve our c

Its 122,000-plus caregivers/employees (including 34,000 physicians) serve in 51 hospitals, more than 1,000 clinics and a comprehensive range of health and social services.

Diagnosing and managing acute, chronic, or episodic health issues in partnership with physicians or independently as permitted.

The nurse practitioner will round and communicate with the surgery teams/residents/attending physicians. The nurse practitioner will participate in the comprehensive care of patients in the inpatient settings and provide multi-disciplinary care coordination, treatment, education, monitoring, and com

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Your Role on the Team Position Summary: Incumbent manages the care of the Advance Heart failure and Mechanical Circulatory Support (MCS) patient population across the continuum in collaboration with physicians and other members of the multidisciplinary team.

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The NP is accountable to, evaluated, and provided feedback by the supervising/collaborating physician, physician designee(s) in the same clinical specialty, or the Administrative Manager. Ability to exercise diplomacy and flexibility in interacting with physicians, nurses, other paramedical personne

Step into a New Adventure - Your Next Role as a Nurse Practitioner Awaits in Santa Ana, California.In the world of healthcare, the most important metrics often revolve around lives transformed and the profound impact of compassion.You've witnessed the significance of timely interventions, heartfelt

Requests physician consultations and multidisciplinary consults. May work as an independent provider and/or under indirect supervision of a supervising physician. Must have Current negative TB test and health screen report or questionnaire clearance by a physician prior to employment.

Diagnosing and managing acute, chronic, or episodic illnesses, either in collaboration with physicians or independently (as credentialed).