Utilization Review Manager (Contra Costa Health Plan)

Full Job Description

Why Join Contra Costa County Health Services?

The Contra Costa Health Department is seeking to fill one (1) Utilization Review Manager position in Contra Costa Health Plan, located in Martinez, CA.

Contra Costa Health Plan (CCHP) is a mission-driven, county-operated managed care organization delivering high-quality health coverage to more than 250,000 members across Medi-Cal, commercial, and beginning in 2026, Medicare-Medi-Cal (D-SNP) lines of business.

We are seeking a strategic, experienced, and collaborative Utilization Review Manager to lead our Utilization Management Department across all lines of business.

This is a pivotal leadership opportunity at a critical moment in CCHP’s growth and transformation.

With increasing regulatory expectations from the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and the implementation of new care models under CalAIM and the upcoming Medicare and Medi-Cal Dual Special Needs Plan (D-SNP), regulatory compliance is more critical than ever.

The Utilization Review Manager will be responsible for leading a team of clinical and administrative staff to ensure timely, compliant, and member-centered utilization management processes.

We are looking for someone who:

• Has demonstrated experience leading utilization review and prior authorization functions within a managed care or health system environment
• Understands federal and state regulatory frameworks, including DHCS, DMHC, CMS, and NCQA standards
• Is an effective people leader who supports staff development, performance management, and cross-functional collaboration
• Can balance strategic vision with operational detail, helping translate evolving regulatory guidance into real-time implementation
• Is comfortable in fast-paced, dynamic environments and has the flexibility to adapt processes and policies as the organization evolves

What you will typically be responsible for:

• Managing and monitoring day-to-day clinical review operations and authorizations
• Leading the development and implementation of utilization management policies and workflows
• Ensuring turnaround time compliance and accuracy in decision-making and member/provider notifications
• Preparing for and responding to audits, including CMS, DMHC, and delegated UM reviews
• Collaborating with internal departments and external providers to support coordinated and efficient member care
• Developing reports and data tools that drive insights and accountability
• Interviewing, hiring, orienting, evaluating, counseling, and recommending discipline of staff
• Supervising and training staff

A few reasons why you might love this job:

• You are passionate about public service and improving care for vulnerable populations
• You thrive in a mission-driven organization focused on innovation and continuous improvement
• You enjoy mentoring staff and shaping a high-performing team
• You are excited by building systems and helping shape the foundation for new programs like D-SNP

A few challenges you might face in this job:

• You will be expected to navigate complex regulatory environments and shifting program requirements
• The organization is in a period of transformation, and legacy processes may require redesign and improvement
• Balancing urgent operational demands with long-term strategic planning can be difficult

Competencies Required:

• Analyzing & Interpreting Data: Drawing meaning and conclusions from quantitative or qualitative data
• Decision Making: Choosing optimal courses of action in a timely manner
• Delivering Results: Meeting organizational goals and customer expectations and making decisions that produce high-quality results by applying technical knowledge, analyzing problems, and calculating risks
• Attention to Detail: Focusing on the details of work content, work steps, and final work products
• Self-Management: Showing personal organization, self-discipline, and dependability
• Writing: Communicating effectively in writing
• Customer Focus: Attending to the needs and expectations of customers
• Leadership: Guiding and encouraging others to accomplish a common goal
• Driving Results: Demonstrating concern for achieving or surpassing results against an internal standard of excellence

Qualifications

License Required: Candidates must possess and maintain throughout the duration of employment: a current, valid, and unrestricted license as a Registered Nurse issued by the California Board of Registered Nursing.

Education: Possession of a bachelor's degree in nursing from an accredited college or university.



Experience: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a managed care organization (i.e. HMO), two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, one (1) year of which must have been in a supervisory capacity.

Substitution: Two (2) additional years in a Nurse Supervisor capacity may be substituted for the Bachelor's degree. A Master's Degree in nursing, hospital or health care administration or a closely related field may be substituted for one (1) year of experience as a Registered Nurse. No substitution is allowed for the required one (1) year of supervisory experience.

Additional Information

Application Filing and Evaluation: Applicants will be required to complete a supplemental questionnaire at the time of application.

Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.Training & Experience Evaluation: At the time of filing, candidates will be required to complete a supplemental questionnaire, which will be used for the training and experience evaluation.

Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated.

The responses to the supplemental questions, at the time of filing, will be evaluated to determine each candidate's relevant education, training, and/or experience as presented on the application and supplemental questionnaire.

(Weighted 100%)The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.

CONVICTION HISTORYAfter you receive a conditional job offer, you will be fingerprinted, and your fingerprints will be sent to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI).

The resulting report of your conviction history (if any) will be used to determine whether the nature of your conviction conflicts with the specific duties and responsibilities of the job for which you have received a conditional job offer.

If a conflict exists, you will be asked to present any evidence of rehabilitation that may mitigate the conflict, except when federal or state regulations bar employment in specific circumstances.

Having a conviction history does not automatically preclude you from a job with Contra Costa County.

If you accept a conditional job offer, the Human Resources department will contact you to schedule a fingerprinting appointment.

DISASTER SERVICE WORKERAll Contra Costa County employees are designated Disaster Service Workers through state and local law.

Employment with the County requires the affirmation of a loyalty oath to this effect.

Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.

EQUAL EMPLOYMENT OPPORTUNITYIt is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.