Utilization Management Manager-Utilization Mgmt- Days - FT

Job Description

Oversee the management of patient care utilization, ensuring appropriate healthcare services are provided while optimizing resource use. This individual will be responsible for leading a team of nurses who review medical necessity, appropriateness and efficiency of healthcare services. Ensure compliance with regulatory requirements and maintain high standards of care.

Responsibilities

• Supervise and lead the UM nursing team and Pre-Certification Specialists, ensuring the review of patient cases for appropriate medical necessity and care protocols
• Develop, implement and maintain UM policies and procedures in accordance with healthcare regulation and organizational standards
• Conduct regular training and provide ongoing support for UR team to improve knowledge and performance
• Collaborate with physicians, other healthcare providers and insurance companies to review and improve treatment plans. Ensure all services are medically necessary and cost effective
• Evaluate and analyze healthcare utilization trends, identify opportunities for improvement and solutions to improve outcome
• Monitor and ensure compliance with regulatory requirements including Medicare, Medicaid and other payer policies
• Prepare and present reports on utilization metrics, case reviews and outcomes to administration leadership groups
• Resolve complex case issues and provide guidance on challenging utilization decisions
• Ensure accurate documentation of all UM reviews, ensuring compliance with internal and external audit
• Foster effective communication between departments, stakeholders and healthcare professionals

Qualifications

Education Requirements

Required : Bachelor Degree

Preferred : Master's Degree

License or Certification Requirements

Required : License

Experience Requirements

Required : 5 years

Preferred : 2 years

Core Competencies

Knowledge :

Skills :

Abilities :

Work Environment : This position may involve working in a variety of clinical and administrative settings, requiring adaptability and a proactive approach to problem-solving.

Physical Demands : Frequent reaching, sitting, walking, and standing may be required. No special coordination beyond that used for normal mobility and handling of everyday objects and materials is needed to perform the job.