Program Manager Care Management & Utilization Management

Program Manager Care Management & Utilization Management

Role Purpose
Lead enterprise-wide Care Management and Utilization Management programs across multiple states, ensuring consistent operating models while accommodating state-specific Medicaid, Medicare, and commercial requirements. The role bridges clinical operations, business transformation, technology, data, compliance, and vendor management.

Key Responsibilities

1. CM/UM Transformation

• Lead strategic transformation initiatives across Care Management, Utilization Management, Prior Authorization, Case Management, Disease Management, and Population Health.
• Establish standardized enterprise processes while supporting state-specific regulatory requirements.
• Identify opportunities to reduce administrative burden, improve member/provider experience, and lower medical costs.
• Drive automation and AI-enabled workflows across authorization and care management.

2. Program Leadership

• Manage a portfolio of concurrent CM/UM initiatives across multiple states and lines of business.
• Establish program governance, roadmaps, milestones, dependencies, risks, and financial targets.
• Coordinate business, clinical, technology, data, compliance, actuarial, and vendor stakeholders.
• Present program status, issues, financial performance, and strategic decisions to executive leadership.

3. Utilization Management

• Lead initiatives involving prior authorization, concurrent review, retrospective review, medical necessity, and utilization optimization.
• Support compliance with CMS, state Medicaid, NCQA, URAC, and other applicable requirements.
• Improve turnaround times and reduce provider abrasion.
• Identify opportunities to leverage clinical intelligence, automation, and AI to improve authorization decisions and workflows.

4. Care Management

• Transform case management, disease management, transitions of care, and complex care programs.
• Improve identification and stratification of high-risk/high-cost members.
• Integrate claims, clinical, pharmacy, social determinants, and provider data to improve care interventions.
• Establish measurement frameworks for clinical outcomes, member engagement, and medical-cost impact.

5. Technology & Data

• Partner with IT and data organizations to modernize CM/UM platforms and supporting data ecosystems.
• Define requirements for workflow, clinical decision support, interoperability, analytics, and reporting.
• Support integration with EHRs, payer platforms, provider systems, CRM, care management platforms, and data platforms.
• Evaluate and implement AI/agentic capabilities for clinical workflows, authorization, documentation, and care management.

6. Multi-State Operations

• Develop a common enterprise CM/UM framework while maintaining flexibility for state-specific requirements.
• Coordinate implementation across multiple health plans, markets, Medicaid programs, and regulatory environments.
• Establish reusable processes, technology components, data models, and implementation playbooks.