Nurse Manager Utilization Management

Assures effective use of Healthcare Organization Resources by studying insurance, governmental, and accrediting agency
standards regarding patient admission, treatment, and length of stay; reviewing admitting diagnoses, medical necessity, and
treatment plans; conducting face-to-face assessments; recommending appropriate levels of care; comparing patient records to
established criteria; evaluating legitimacy of treatment and length of stay; maintaining utilization plans.

Key Responsibilities

• Determines healthcare organization utilization standards by studying insurance, governmental, and accrediting agency standards regarding patient admission, treatment, and length of stay; recommending organization standards. 
• Guides healthcare organization utilization actions by researching, developing, writing, and updating utilization review
  policies, procedures, methods, and guidelines; recommending changes. 
• Approves patient admissions by reviewing admitting diagnoses, medical necessity, and treatment plans; conducting
  face-to-face assessments; recommending appropriate levels of care; referring sub-standard cases to utilization review
  committee; determining patient review dates. 
• Monitors healthcare organization utilization by comparing patient records to established criteria; evaluating legitimacy of
  treatment and length of stay; conferring with medical and staff personnel; conducting discharge reviews. 
• Prepares utilization review information and reports by collecting, abstracting, analyzing, and summarizing data and
  trends. 
• Supports healthcare organization utilization review committee by providing data and recommendations; scheduling and
  organizing patient reviews; maintaining utilization plans. 
• Enforces utilization review requirements by conducting surveys, audits, and retrospective reviews; coordinating with
  patient care teams. 
• Facilitates utilization review reporting by ensuring availability of forms to organization areas; designing new forms.
• Protects healthcare organization value by keeping information confidential; cautioning others regarding potential
  breaches. 
• Maintains healthcare organization legal and accreditation compliance by developing policy positions concerning federal,
  state, and local regulations, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards;
  anticipating emerging issues. 
• Improves utilization review job knowledge by attending educational workshops; reviewing professional publications;
  establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies. 
• Responsible for managing the utilization review RN’s productivity, quality of reviews and overall performance. 
• Responsible for managing the utilization review RN’s annual competencies, licensure renewal and competing each
  associate’s annual review. 
• Contributes to utilization review and healthcare organization success by welcoming related, different, and new requests
  and helping others accomplish job results. Will also function as a working manager and assist the UR/Denials
  Management Coordinators as appropriate.

What We Offer

• Culture- Collaborative, inclusive, diverse, and supportive work environment.
• Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.
• Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.
• Reputation- Regional & National recognition, advanced technology, and leading medical innovations.

Qualifications

• BSN from an accredited School of Nursing required, Master's degree preferred.
• 3-4 years Utilization Review experience required.
• 2 years of supervisory or management experience preferred.
• Active MD RN License or Active Compact State RN and Basic Life Support for Healthcare providers required.