Utilization Management Manager-Utilization Mgmt- Days - FT

Job DescriptionOversee 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.ResponsibilitiesSupervise and lead the UM nursing team and Pre-Certification Specialists, ensuring the review of patient cases for appropriate medical necessity and care protocolsDevelop, implement and maintain UM policies and procedures in accordance with healthcare regulation and organizational standardsConduct regular training and provide ongoing support for UR team to improve knowledge and performanceCollaborate with physicians, other healthcare providers and insurance companies to review and improve treatment plans. Ensure all services are medically necessary and cost effectiveEvaluate and analyze healthcare utilization trends, identify opportunities for improvement and solutions to improve outcomeMonitor and ensure compliance with regulatory requirements including Medicare, Medicaid and other payer policiesPrepare and present reports on utilization metrics, case reviews and outcomes to administration leadership groupsResolve complex case issues and provide guidance on challenging utilization decisionsEnsure accurate documentation of all UM reviews, ensuring compliance with internal and external auditFoster effective communication between departments, stakeholders and healthcare professionals QualificationsEducation RequirementsRequired: Bachelor DegreeBachelor of Science in Nursing, with an active unrestricted licensePreferred: Master's Degree Nursing or other clinical discipline, Health Administration, Finance, Business Administration, or a related fieldLicense or Certification RequirementsRequired: LicenseNursing degree (RN, BS, BSN, or advanced degree) and unrestricted active nursing license Experience RequirementsRequired: 5 yearsNursing experience with at least 2 years in Utilization Management or case management role Preferred: 2 years Leadership or management experience in nursing or related fieldCore CompetenciesKnowledge:In depth knowledge of healthcare utilization management processes, medical terminology and clinical guidelinesFamiliarity with payer requirements and regulation including Medicare, Medicaid and private insurersWorking knowledge of applications that are used to enhance utilization management based on evidenced based approach and guidelinesStrong knowledge of Microsoft Office applications Skills: Analytical Skills: The ability to analyze large data sets, determine trends, synthesize results, and deliver prioritized details through effective reportingCommunication Skills: Strong communication and interpersonal skills for effective collaboration and educationProblem-Solving Skills: The capacity to understand issues, derive many potential solutions, troubleshoot discrepancies, and understand systematic approaches to problem resolution Abilities: Attention to Detail: Precision is essential when reporting critical analysis to inform decision-making and operational changeTime Management: Managing multiple tasks and deadlines while prioritizing work is essential in a fast-paced healthcare environmentTechnology Proficiency: Beyond EHR systems, familiarity with various billing software and technology toolsWork Environment: This position may involve working in a variety of clinical and administrative settings, requiring adaptability and a proactive approach to problem-solving.