Description
Position Title: Manager, Utilization Management (UM)
Company: Southeast Primary Care Partners – Physicians First ACO (PFACO)/Physicians First Health Network (PFHN)
Location: Primarily Remote | Occasional Travel Required
Position Overview Physicians First ACO (PFACO) and Physicians First Heatlh Network (PFHN), divisions of Southeast Primary Care Partners, is seeking an analytical and proactive Manager, Utilization Management (UM) to monitor, evaluate, and optimize healthcare utilization across a network of independent provider practices. This role is central to improving total cost of care and patient outcomes in a value-based care environment. The UM Manager will work closely with our Analytics Team to leverage claims data, population health reports, and EMR data. The UM Manager’s goals are to identify utilization trends, uncover drivers of high spend, and implement actionable strategies in collaboration with clinicians, patients, and senior leadership.
The role involves conducting reviews for medical necessity and the utilization of ancillary services to ensure the appropriate level of patient care. The Manager determines the appropriate level of patient care through collaboration with physicians, reviews, monitors, evaluates, and coordinates patient stays to assure services are timely and efficient, maintains appropriate documentation, and ensures compliance with federal, state, and local requirements, as well as organizational policies and procedures.
The ideal candidate brings strong utilization management experience (in payer, provider, or hospital settings), thrives in a data-driven environment, and is comfortable working independently while influencing provider behavior.
Requirements
Key Responsibilities
Utilization Analysis & Monitoring
- Analyze daily claims, population health data, and EMR data to identify utilization trends and cost drivers, incorporating industry best practices such as predictive analytics and risk stratification models (e.g., aligned with CMS ACO benchmarks).
- Monitor key metrics, including Emergency Department (ED) utilization; admission and readmission rates; potentially avoidable admissions; post-discharge follow-up gaps (7–14 days); Skilled Nursing Facility (SNF) utilization and bounce-backs; hospice utilization patterns (including prolonged stays); high-cost imaging, procedures, and specialist utilization; and identify variation in utilization patterns across practices and providers.
Develop a UM Team
- Develop and lead a strong UM team to support multiple payers, ACOs, and physician practices, fostering interdisciplinary collaboration and ongoing training in evidence-based utilization review protocols (e.g., per URAC or NCQA standards).
Practice & Clinician Engagement
- Identify physician practices’ patients with high utilization and spend.
- Conduct targeted outreach to share actionable, data-driven insights; highlight opportunities to reduce unnecessary utilization; and support workflow improvements and care coordination, drawing on best practices like shared decision-making tools and provider education sessions.
- Deliver clear, practical recommendations tailored to each practice.
Patient-Level Intervention
- Identify high-risk, high-cost patients using claims and analytics tools.
- Collaborate with practices on care management strategies, incorporating best practices such as patient-centered care plans and motivational interviewing techniques.
- Conduct patient outreach (as appropriate) to reinforce care plans; promote appropriate site-of-care utilization (e.g., ED avoidance); and address gaps in follow-up care.
Clinical Collaboration
- Partner closely with the Medical Director to review complex cases and utilization patterns; align on clinical appropriateness and interventions; develop strategies to reduce avoidable utilization; and escalate cases requiring clinical review or physician input, ensuring adherence to evidence-based guidelines (e.g., from AHRQ).
Systems Navigation & Workflow
- Navigate multiple EHR systems across independent practices.
- Extract and interpret clinical and operational data to support initiatives, while maintaining HIPAA compliance and data security best practices.
- Utilize population health and analytics platforms to guide daily workflow, optimizing for efficiency and Triple Aim outcomes.
Performance Improvement & Reporting
- Track and report on utilization trends, interventions, and outcomes.
- Support development of dashboards and performance reports, incorporating continuous quality improvement methodologies (e.g., Plan-Do-Study-Act cycles).
- Contribute to ACO-wide strategies to reduce costs and improve quality, ensuring compliance with OSHA standards for safe remote and on-site work environments and FLSA regulations for fair compensation and overtime.
Qualifications
Required
- 3–5+ years of experience in Utilization Management, Care Management, or a related field.
- Bachelor’s degree in Nursing, Healthcare Administration, Public Health, or a related field.
- Clinical background (currently licensed LPN, RN, or equivalent).
- Experience in payer, hospital/health system, or ACO environment preferred.
- Strong understanding of healthcare utilization drivers; claims data analysis; transitions of care; and care coordination.
Preferred
- Certification (e.g., CCM, CPUR, or equivalent) is a plus.
- Experience in value-based care models (ACO, Medicare Advantage, Commercial) highly desirable.
Core Competencies
- Strong analytical skills with the ability to translate data into actionable insights.
- Excellent communication skills with the ability to engage and influence providers.
- Ability to work independently and manage priorities effectively.
- Comfortable navigating multiple systems and adapting to varied workflows.
- High level of professionalism and discretion.
Work Environment
- Primarily remote role with occasional travel to physician practices (travel may include adherence to OSHA safety protocols for on-site visits).
- Independent position with a high level of autonomy, requiring self-motivation in a virtual setting.
- OSHA Compliance Requirements: As a hybrid remote position with occasional travel to physician practices, ensure adherence to OSHA standards primarily during on-site visits. This includes proper ergonomics for any prolonged standing, safe lifting techniques (e.g., lifting up to 50 lbs),. For remote work, focus on ergonomic setup of home office to comply with OSHA guidelines for virtual environments.
Why Join PFACO?
- Play a key role in driving value-based care transformation.
- Work directly with leadership to impact cost and quality outcomes.
- Shape utilization strategies across a diverse provider network.
- Operate in a data-driven, clinically integrated environment.
Equal Opportunity Employer Southeast Primary Care Partners is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.