Utilization Review Manager (Contra Costa Health Plan)

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.

• 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

• 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

• 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

• 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

• 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

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.
 

1. 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.
   
   
2. 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%)