Supervisor, Utilization Management

Vālenz^® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.

About This Opportunity:
As a Supervisor of Utilization Management, you will lead a team of utilization review nurses by providing guidance, mentorship, and training to ensure timely, high-quality clinical reviews. Using your leadership and clinical expertise, you will collaborate with organizational leaders to refine utilization management policies, support adherence to evidence-based guidelines, and promote a culture of continuous improvement. In this role, you will conduct clinical reviews, ensure regulatory compliance, and facilitate communication with providers and payers. You will also monitor team performance, coach staff for professional growth, and identify opportunities for quality improvement and cost containment, while consistently upholding professional and ethical standards.

Things You’ll Do Here:

• Supervise and support a team of Utilization Review Nurses, providing guidance, mentorship, and ongoing training.
• Collaborate with leadership to develop, implement, and maintain UM policies, procedures, and clinical guidelines.
• Monitor team performance against established productivity and quality goals, ensuring timely and accurate work.
• Deliver clear communication, coaching, and educational support to enhance team performance and compliance.
• Conduct clinical reviews to assess medical necessity and appropriateness of services, referring to Case Management or other programs as needed.
• Evaluate treatment plans and medical records to ensure alignment with evidence-based criteria and best practices.
• Ensure timely communication of utilization decisions with healthcare providers, payers, and clients.
• Collaborate with providers and internal teams to promote efficient resource use and identify opportunities for quality improvement and cost containment.
• Ensure compliance with regulatory requirements and accreditation standards including Medicare, Medicaid, and URAC.
• Maintain complete, accurate documentation of all UM activities and decisions.
• Stay current with industry regulations, standards, and emerging best practices in utilization management.
• Uphold strict confidentiality and demonstrate high standards of professional and ethical conduct.
• Perform other duties as assigned.

Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.

What You’ll Bring to the Team:

• 5+ years of Utilization Management or Quality Improvement experience in managed care.
• 2+ years of clinical experience in an acute care or surgical hospital setting.
• Active RN license in the state of residence.
• Proficient in ICD-10, CPT, HCPCS, Revenue codes, and CMS/URAC guidelines.
• Familiar with evidence-based criteria such as MCG and health plan policies.
• Strong relationship-building skills with clear, effective communication.
• Able to thrive in a fast-paced, detail-oriented, deadline-driven environment.

A plus if you have:

• Health insurance experience
• Prior leadership experience
• MCG certification
• Compact State Nursing License

Where You’ll Work:This is a fully remote position, and we’ll provide all the necessary equipment!

• Work Environment: You’ll need a quiet workspace that is free from distractions.
• Technology: Reliable internet connection—if you can use streaming services, you’re good to go!
• Security: Adherence to company security protocols, including the use of VPNs, secure passwords, and company-approved devices/software.
• Location: You must be US based, in a location where you can work effectively and comply with company policies such as HIPAA.

Why You'll Love Working Here

Valenz is proud to be recognized by Inc. 5000 as one of America’s fastest-growing private companies. Our team is committed to delivering on our promise to engage early and often for smarter, better, faster healthcare.With this commitment, you’ll find an engaged culture – one that stands strong, vigorous, and healthy in all we do.

Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA
• 401K with company match and immediate vesting
• Flexible working environment
• Generous Paid Time Off to include vacation, sick leave, and paid holidays
• Employee Assistance Program that includes professional counseling, referrals, and additional services
• Paid maternity and paternity leave
• Pet insurance
• Employee discounts on phone plans, car rentals and computers
• Community giveback opportunities, including paid time off for philanthropic endeavors

At Valenz, we celebrate, support, and thrive on inclusion, for the benefit of our associates, our partners, and our products. Valenz is committed to the principle of equal employment opportunity for all associates and to providing associates with a work environment free of discrimination and harassment. All employment decisions at Valenz are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. We will not tolerate discrimination or harassment based on any of these characteristics.

Originally posted on Himalayas