Scientific Affairs Manager at USP enhancing public health quality standards in LATAM region. Engaging stakeholders and providing scientific guidance for pharmaceutical compliance and standards implementation.
About the role
- Manager of Utilization Management responsible for operational leadership and compliance oversight of programs at Telligen. Overseeing staff and workflows in a compliance-focused environment with performance management.
Responsibilities
- Manage the day-to-day operations of Utilization Management programs across multiple contracts and populations.
- Lead planning, implementation, evaluation, and ongoing management of UM workflows to ensure compliance with regulatory, accreditation, and contractual requirements.
- Monitor key UM performance indicators including timeliness, determination accuracy, appeal overturn rates, and documentation quality. When risks or gaps are identified, leads root cause analysis and corrective action planning.
- Ensure UM operations remain compliant with applicable federal and state regulations, client requirements, and accreditation standards (e.g., URAC).
- Partner with Quality and Compliance teams to support audits, corrective action plans (CAPs), policies, procedures, and readiness activities.
- Lead continuous improvement initiatives focused on clinical consistency, medical necessity application, letter accuracy, peer review processes, and regulatory adherence.
- Maintain financial accountability for assigned UM contracts, including staffing models, productivity expectations, and budget adherence.
- Monitor operational performance against contractual service level agreements (SLAs) and utilization benchmarks.
- Participate in proposal development, pricing inputs, and operational feasibility discussions as a UM subject matter expert.
- Coach, guide, and direct UM staff to achieve individual, team, and organizational objectives.
- Ensure appropriate training, competency validation, and ongoing education for UM nurses, physician reviewers, and support staff.
- Foster a culture of accountability, clinical integrity, and continuous improvement consistent with Telligen’s Management Philosophy that managers coach, engage, and support people to achieve results.
- Represent Telligen in meetings with clients, providers, regulators, and internal stakeholders related to UM operations.
- Collaborate with Medical Directors, Compliance, Quality, and Operations leadership to resolve issues and improve service delivery.
- Stay current on utilization management trends, regulatory updates, accreditation changes, and evolving medical management best practices.
Requirements
- Four year degree in nursing, health care, business, public health or a related field and/or equivalent training and/or experience
- Graduate of an accredited nursing program (ACEN, CCNE), with an active, unrestricted RN license
- 5 years experience in healthcare environment including care management and/or health care quality improvement
- 3 – 5 years managing projects and/or a professional staff
- Demonstrated experience working in a fast paced and deadline driven environment
- Up to 20% local and overnight travel
Benefits
- None specified
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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