Utilization Review Manager

American Medical Administrators (AMA) is seeking a skilled and compassionate Utilization Review Manager to join our growing healthcare team at Missouri Valley Regional Medical Center in Marshall, Missouri.

Position Overview
The Utilization Review Nurse is responsible for reviewing patient admissions, continued stays, and level-of-care needs to ensure appropriate utilization of hospital services and compliance with medical necessity criteria and payer requirements. This is a hybrid position and works closely with physicians, nursing staff, case management, and insurance representatives to support quality patient care while helping minimize delays and prevent avoidable claim denials.

Key Responsibilities

• Review medical records and clinical documentation for medical necessity and appropriate level of care.
• Conduct admission, concurrent, and retrospective utilization reviews.
• Evaluate impatient and observation status based on established clinical criteria and payer guidelines.
• Communicate with physicians and clinical staff regarding documentation and medical necessity.
• Obtain and maintain insurance authorizations for inpatient services and procedures as needed.
• Collaborate with case management and discharge planning teams to facilitate appropriate transitions of care.
• Identify potential delays in treatment, discharge barriers, and opportunities to improve resource utilization.
• Communicate with insurance companies and managed care organizations regarding authorization and continued-stay reviews.
• Assist with appeals and denial management when services are questioned or denied by payers.
• Maintain accurate and timely documentation of utilization reviews and authorization activities.
• Monitor utilization trends and identify opportunities for improved efficiency and patient outcomes.
• Maintain knowledge of Medicare, Medicaid, commercial payer requirements, and applicable hospital policies and regulations.
• Participate in quality improvement and utilization management initiatives.

Qualifications

• Registered Nurse (RN) preferred/required, depending on hospital requirements.
• Bachelor's degree in Nursing preferred.
• Previous hospital clinical experience required.
• Experience in utilization review, case management, care management, or clinical documentation preferred.
• Knowledge of medical necessity criteria and insurance authorization processes.
• Strong clinical assessment, communication, organization, and critical-thinking skills.
• Ability to work collaboratively with physicians, nurses, case managers, and payer representatives.
• Familiarity with electronic medical records and documentation systems.

Schedule
Full-time position with schedule based on hospital needs. Some positions may include weekends, holidays, or on-call responsibilities.

Pay: $80,000.00 - $95,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $80,000 - $95,000