Job Summary

The Manager of Utilization Management has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or supporting effective and efficient processes for appropriate admission status determination based on regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for the oversight of admission, concurrent and retrospective UM-related reviews. Collaborates with multiple leaders at various levels within the organization for the purpose of supporting and improving the UM Program. Ensures that appropriate data is tracked, evaluated, and reported.

Essential Functions

• Manages the Utilization Management development; monitors and maintains department specific goals and objectives ensuring alignment with system strategy, vision, mission, and values.
• Monitors the effectiveness/outcomes of the UM program by identifying and applying appropriate metrics; evaluating the data; reporting results to various audiences; and designing and implementing process improvement projects as needed.
• Leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Maintains current and accurate knowledge of commercial and government payers and regulatory bodies related to UM activities.
• Ensures the UM program maintains documented, up-to-date policies and procedures and UM key processes have valid outcome measures monitored for compliance and improvement.
• Provides leadership, mentoring, and coaching to direct reports.
• Promotes effective communication and collaboration among members of the Care Management team; Physician Advisor(s); Hospital Billing; Coding; Corporate Compliance; IAS (Information Analytics Services); and other disciplines as appropriate.
• Facilitation, participation, and oversight of the following:
  • Annual updates of Utilization Review Screening Tools (i.e., InterQual/Milliman Care Guidelines) and Interrater Reliability in collaboration with IAS
  • Provides ongoing education and competencies to utilization review nurses, senior utilization review nurses, and other colleagues as desired
  • Participation in UM Committee and UM activities
• Serves as a clinical leader and system resource UM expert
• Ensures departmental compliance with regulatory standards are met and maintained.

Physical Requirements

Work requires walking, standing, lifting, reaching, bending, and stooping. Must lift a minimum of thirty-five pounds. Ability to travel/drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be able to respond quickly to changes in assignments. Occasional intermittent noise and exposure to conditions such as dust, fumes, and chemicals.

Education, Experience and Certifications

Master’s degree required. Current RN license or temporary license as a Registered Nurse Practitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Practitioner required in the state where the RN works. Two years of related nursing experience required; five years preferred. Experience includes but not limited to case management/discharge planning/utilization management/denial management/medical necessity review in one of the following settings: acute care, home care, long term care, physician office, or insurance plan. Appropriate Professional certification required within 3 years of hire per Clinical Care Management Certification Guidelines.

Clinical competence and critical thinking in disease management and case management principles. Must possess excellent interpersonal communication and negotiation skills, problem-solving skills, strong organizational and time management skills, and the ability to work independently and as a member of the care team.