Hybrid Quality Improvement Manager – Utilization Management

at Telligen

• Job title: Quality Improvement Manager – Utilization Management
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, West Des Moines, United States

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