Nurse Manager Utilization Management

General Summary of Position

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 yearsUtilization 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.

This position has a hiring range of $110,635.20 - $190,340.80