SUMMARY
We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full‑time role and will be required to work onsite.
Purpose of this position: Manages the design, development, implementation, and monitoring of utilization review functions. Oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication, and role modeling. Functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day‑to‑day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.
RESPONSIBILITIES
Participates in the development and management of department budgets and productivity targets
Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
Collaborates with department director and professional development specialist to develop standard work and expectations for the utilization review process, including timely medical necessity screening to ensure patients are placed at the appropriate patient status and level of care, professional communication with physicians and nurses and other members of the care team
Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
Ensures processes are in place for proactive reviews of surgical and other procedures to confirm accurate perioperative pre‑authorization and patient class order reconciliation process. Assesses compliance to regulatory and health plan requirements for authorization, including Medicare
Inpatient Only List and communicates to provider to obtain accurate order prior to procedure and post procedure
Ensures UR Coordinators and Clinical Coordinators identify, document, and communicate avoidable days and delays in services that may prolong length of stay; analyzes data to monitor trends for opportunities to improve services. Partners with hospital Director Transitional Care to report avoidable days, trends, and actions to UR Committees, as appropriate
Partners with Physician Advisor to engage in second level review and working with attending physicians to document completely to ensure patient class determinations
Serves as expert resource for all Medicare Notification Letters and ensures appropriate distribution of all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirements and ensure correct billing
Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to analyze one‑day Medicare inpatient stays and identify opportunities to improve
Develops and implements process to manage and respond to all concurrent and post‑discharge third‑party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including, but not limited to; Peer‑to‑Peer as appropriate, written appeal letters when indicated, documentation of interventions and outcomes and monitor to identify opportunities to improve processes for denial
prevention
Serves as the internal expert on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers, as appropriate
May participate in the Utilization Review Committee to present medical necessity data and outcomes and partners with care management leadership to develop action plans for improvement
Performs other duties as assigned
QUALIFICATIONS
Minimum Qualifications
Master’s degree in nursing or related field. If the Master’s degree is in a related field, the individual must have a Bachelor’s degree in Nursing from an accredited program
Individuals who do not have a Master’s degree in either nursing or a related field must have a Bachelor’s degree in Nursing and be actively enrolled in an approved Master’s or Doctorate nursing or related field program. Enrollment in the progressive ADN to Master’s Degree Program also fulfills this requirement. The Master’s or Doctorate degree must be obtained within 5 years of hire as a condition of continued employment
Three to five (3 to 5) years of professional leadership experience (i.e., charge nurse, team leader, preceptor, committee chair, etc.)
Five (5) years clinical experience
A minimum of one (1) year of utilization review experience
Preferred Qualifications
Master’s degree
Experience in surgery, emergency and/or critical care
Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity
Knowledge/ Skills/ Abilities
Ability to deliver financial results for areas of accountability
Knowledge of or ability to learn financial management related to UR function and reporting, quality improvement processes, and human
resources management
Able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding
resource allocation needs for future planning purposes
Able to communicate effectively in writing and verbally, ability to interact with a wide variety of individuals, and handle complex and confidential
situation
Ability to lead, delegate, analyze information and problem solve
Demonstrates evidence of strong skills in confidentiality, integrity, creativity, and initiative
License/Certifications
Current Registered Nurse licensure upon hire
National certification of any of the following: CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), ACM (Accredited Case Manager) required or completed within three years of hire