Utilization & Medical Management RN Manager

Artemis Healthcare Partners is seeking an experienced Registered Nurse with a background in managed care, healthcare quality, utilization management, or clinical operations to join our client's Medical Management team!Position Name: Medical Management Manager – Registered Nurse (RN)Location: Fresno, CA (Onsite)Employment Type: Direct-Hire & PermanentSetting: Managed Care/Health PlanPay: $95,000-$124,377Shift: Mon-Fri, 8am-5pm | Status: ExemptQualifications:Required:- Active Registered Nurse (RN) license in CA.- Bachelor's degree in Nursing, Healthcare Administration, Public Health, Public Administration, or a related healthcare field.- 5+ years of progressive experience in managed care, healthcare quality, utilization management, case management, clinical operations, and/or healthcare program/project management.- Administrative nursing experience within utilization management, case management, healthcare quality, performance improvement, regulatory oversight, or a related function.- Clinical nursing background with a strong understanding of care delivery across hospital and/or outpatient settings.- Experience with healthcare audits, regulatory requirements, clinical reviews, quality initiatives, and/or evaluation of healthcare programs or services.- Strong analytical skills with experience reviewing healthcare data, clinical documentation, audit findings, reports, and performance trends.- Proficiency with Microsoft Excel and Word, including spreadsheets, detailed reports, document review, editing, and redlining.- Ability to work independently, manage multiple priorities, and effectively collaborate within a small, high-performing team.Preferred:- Master’s degree in Nursing, Healthcare Administration, Public Health, Public Administration, or a related healthcare field.- CPHQ or comparable healthcare quality certification.- Previous experience within a health plan or managed care organization supporting Medicaid/Medi-Cal, Medicare, and/or commercial populations.- Healthcare quality experience within a hospital, medical group, outpatient setting, or managed care environment.- Previous leadership or supervisory experience, including oversight of clinical and/or administrative staff.Work Environment:This is primarily an onsite administrative leadership position in Fresno, CA and does not involve direct patient care. The role is heavily focused on healthcare data, reports, audits, policies, clinical documentation, regulatory requirements, and oversight of delegated health plan activities.Job Summary:- Join a small, highly collaborative Medical Management leadership team responsible for overseeing clinical and care-related activities performed on behalf of the health plan.- Directly supervise Medical Management staff, including clinical and administrative team members, while maintaining responsibility for an individual portfolio of projects and deliverables.- Review the performance of delegated health plan functions across areas such as utilization management, case management, pharmacy, credentialing, appeals and grievances, and other clinical programs.- Coordinate healthcare audits and evaluate findings, trends, and supporting documentation to identify areas requiring follow-up or improvement.- Review clinical and operational data to assess whether programs and services are producing appropriate outcomes across the continuum of care.- Maintain and update Medical Management policies, procedures, reports, workplans, and other documentation in response to operational and regulatory requirements.- Support preparation for state and regulatory reviews by organizing documentation, reviewing clinical files, assessing audit readiness, and following identified issues through resolution.- Work closely with the Senior Director of Medical Management and Chief Medical Officer to evaluate health plan performance and identify opportunities to strengthen quality, utilization, care management, and patient outcomes.- Participate in quality improvement, utilization management, case management, HEDIS, appeals and grievances, and other clinical or operational committees and workgroups.- Analyze reports, spreadsheets, audit results, and healthcare performance data and translate findings into actionable follow-up with internal and external stakeholders.- Operate independently within an integrated workflow where work products are reviewed collaboratively across the Medical Management leadership team.- Serve as a key member of a lean department with the opportunity to expand responsibilities and potentially progress into future Medical Management leadership.Benefits:- Medical, Dental, Vision- Health Savings Account (HSA)- Paid Time Off (PTO)- AD&D and Life Insurance- 457 Retirement Plan with employer match up to 6% + additional $200 monthly employer contribution- Company-paid Gym Membership- Cell Phone Expense Reimbursement- Annual performance evaluation with potential merit increase- Additional employer-sponsored benefits