Utilization Review Manager

The Manager for Utilization Review is responsible for the leadership and management of the centralized Virtual Utilization Management Program and maintaining the support structure within the department for achieving clinical and operational excellence, expected deliverables of the Program in relation to UM efforts, to include the authorization, denials and appeals of inpatient and observation or outpatients. The Manager will also assume the system program compliance, program development and strategy responsibilities in collaboration with the Managers of Bedded Insurance Authorization, Pre-Authorization Diagnostic, Pre-Registration and Surgical Authorization. The Manager for Utilization Review is also responsible for collaboration with the local market hospital-based UM leaders and physician advisors in addition to: Coding, Care Coordination, Clinical Documentation Specialists and Health Information Management. Collaborates extensively with other members of the health care team to provide data and solution development processes.

This position pays between $92,400 – $138,600 based on experience

Job Competencies

Decision Making - Makes decisions by gathering, analyzing, and interpreting information; chooses the best course of action by establishing clear decision criteria, generating and evaluating alternatives, and making timely decisions. Courage - Proactively confronts difficult issues and effectively participates in challenging conversations; makes hard choices and takes bold action in the face of opposition or fear. Refuses defeat. Influencing - Uses effective persuasion techniques to gain acceptance of ideas and commitment to actions that support specific outcomes. Coaching & Developing Others - Partners with individuals' and supports their development of knowledge, skills, and abilities; empowers them to unlock their potential and maximize performance and growth knowing that developing you makes us better. Emotional Intelligence - Establishes and sustains trusting relationships by accurately understanding and interpreting one's own and others' emotions and adapts behaviors to accomplish intended results. Creating an Inclusive Environment - Makes decisions and initiates action to ensure that policies and business practices leverage the capabilities and insights of individuals with diverse backgrounds, cultures, styles, abilities, and motivation.

Essential Job Functions

Develops and manages the Medical Management department activities to meet department and corporate targets and goals.

Based upon strategic initiatives and departmental goals develops a UM work plan annually and report completed activities to the Director of the Financial Clearance Center, VP for Revenue Cycle Services and the Corporate Director of Care Management services for BSHSI. Oversees operational activities of the Virtual UM staff. Provide direct support and resources to Care Coordination to effectively improve LOS and excess days. Provide indirect support to CDS Director to manage and oversee the operational effectiveness of Clinical Documentation department. Participates on committees and conducts studies as necessary to demonstrate improvement in Denial/Appeal processes.

• Proficient in negotiating complex systems to effect positive change.
• Must possess skills required to run a fiscally responsible program while ensuring constant improvement.
• Actively involved in process redesign to eliminate excess days and decrease overall length of stay for inpatients.
• Tracks and trends program compliance. Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, and the department managers for Revenue.

Monitors and evaluates UM staffing productivity and effectiveness.

• Manages UM (Denial/Appeal) staff to decrease number of IP/OBV denials, improve appeal outcomes and address issues resulting in failed bill report.
• Collaborates with facility-based Care Coordination staff to maximize appropriate level of care and decrease length of stay.
• Proficient in communicating clearly and effectively with multiple constituents.
• Proficient on computer usage, esp. database and spreadsheet analysis.

Review the department program to ensure compliance to state and regulatory guidelines.

• Broad knowledge and skilled use of MCG or nursing criteria guidelines
• Broad knowledge of insurance regulations and Medicare and Medicaid guidelines.

Identify staff development opportunities and evaluation tasks for UM staff.

• Ownership of UM staff annual employee engagement with active action plan to address issues.

Develop departmental budget with Director of Utilization Management and AVP of Utilization Management. Accountable for meeting and managing departmental goals and budgets. Negotiates for budgetary dollars FTE's necessary to support business initiatives for department sections' future growth when needed.

• Review monthly department budget reports, UM and design action plan to address budget variances
• Other duties as assigned.

Experience We Love

• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI.
• This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.

Required Minimum Education

• 2 Year/ Associates Degree Nursing / Preferred Education: 4 year/ Bachelors Degree Nursing

Required License

• Current unrestricted license to practice nursing in the resident State

Required Certification

• MCG Certification required within 6 months of hire