Manager Of Utilization Review
The Manager of Utilization Review works closely with the Director of Clinical Performance and the internal Physician Advisor to ensure compliance with regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. This role maintains up-to-date knowledge of the regulatory landscape, including CMS Conditions of Participation (CoPs), Medicare billing regulations, and The Joint Commission (TJC) standards. The Manager collaborates with Patient Financial Services, external Physician Advisor groups and the denial management team to ensure that utilization review processes support compliant denial prevention and accurate billing and reimbursement practices. They are responsible for organizing and overseeing the systems and services necessary for effective utilization review and case management operations. In addition, the Manager assumes day-to-day responsibility for process and performance improvement initiatives related to RN Case Managers involved in utilization management. This includes monitoring key performance indicators, identifying workflow inefficiencies, and implementing evidence-based strategies to enhance operational effectiveness. The Manager understands the compliance and financial implications of utilization review activities and demonstrates a strong commitment to continuous improvement. They proactively optimize workflows, support staff education, and ensure that documentation and review practices meet both clinical and regulatory standards while facilitating efficient care delivery and reimbursement.
Education Qualifications :
- Bachelor's Degree Bachelor's of Science in Nursing (BSN). Required
- Master's Degree Related health field. Preferred
Experience Qualifications :
5 years Acute Care Experience Required2 years Utilization Management / Case Management experience PreferredSkills and Abilities :
Must have excellent interpersonal and communication skills. Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. (Required proficiency)Must demonstrate the ability to work independently and to complete work in a timely manner. (Required proficiency)Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. (Required proficiency)Word processing, Spreadsheets, Healthcare software, Payroll, Internet software, E-mail, Inventory, Database software, Contact Management (Required proficiency)Licenses and Certifications :
Registered Nurse - KSBN RequiredCertified Professional Utilization Review (CPUR) PreferredMCG Care Guidelines Specialist Certification PreferredWhat You Will Do :
Oversee Utilization Review Operations : 1. Manage daily operations of the utilization review team to ensure timely and accurate reviews, status determinations, clinical submissions and authorizations. 2. Supervise and mentor UR nurses and specialists, providing training and performance evaluations. 3. Facilitate the standardization of processes among all staff. 4. Ensures timely and accurate submissions by the UM staff to support authorization for services, in compliance with regulatory and payer requirements. 5. Collaborates closely with clinical teams, case managers, and payers to facilitate efficient care delivery and reimbursement. 6. Conducts internal audits of utilization review activities to ensure adherence to federal and state regulations and prepares for external audits or surveys.Applies organization-approved care guidelines (e.g., MCG) and other evidence-based utilization review criteria to guide decision-making and provide ongoing education to UM, Case Management staff, and other departments.Act as a liaison between clinical departments, finance, and administration to align utilization goals.Stay current with changes in healthcare laws, payer requirements, and clinical guidelines.Ensure compliance with CMS, Joint Commission, NCQA, and other regulatory bodies.Responsible and accountable for providing quality monitoring of the organization's UM scorecard in collaboration with the Clinical Analytics team.Works closely with Clinical Performance Director and the Clinical Documentation and Health Information Management teams to support appropriate documentation to aid in medical necessity denial prevention.Works closely with the physician advisor to : 1. Assist with level of care and length of stay management. 2. Assist with the denial management process. 3. Review and make suggestions related to resource and service management. 4. Provide feedback to staff regarding level of care length of stay, and quality issues. 5. Review cases that indicate a need for issuance of a hospital notice of non-coverage / Important Message from Medicare. 6. Provide ongoing education related to necessary documentation to support acute care services.Technology and System Optimization : 1. Evaluate and implement software tools to streamline utilization review workflows. 2. Monitor system performance and recommend enhancements.Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care.Responds to and recognizes the need to engage leadership for complex case reviews and or system needs to support appropriate management of resources.Represents the UM / case management department on various hospital committees to enhance and foster optimal UM / case management outcomes.Creates an environment in which staff contributes to decision making.Travel Requirements :
10% Travel within facilitiesRequired for All Jobs :
Complies with all policies, standards, mandatory training and requirements of Stormont Vail HealthPerforms other duties as assignedPatient Facing Options :
Position is Not Patient FacingRemote Work Guidelines :
Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.Stable access to electricity and a minimum of 25mb upload and internet speed.Dedicate full attention to the job duties and communication with others during working hours.Adhere to break and attendance schedules agreed upon with supervisor.Abide by Stormont Vail's Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.Remote Work Capability :
HybridScope :
Has Supervisory ResponsibilityNo Budget ResponsibilityPhysical Demands :
Balancing : Occasionally 1-3 HoursCarrying : Occasionally 1-3 HoursClimbing (Stairs) : Rarely less than 1 hourCrouching : Rarely less than 1 hourDriving (Automatic) : Rarely less than 1 hourEye / Hand / Foot Coordination : Frequently 3-5 HoursFeeling : Occasionally 1-3 HoursGrasping (Fine Motor) : Occasionally 1-3 HoursGrasping (Gross Hand) : Occasionally 1-3 HoursHandling : Occasionally 1-3 HoursHearing : Continuously greater than 5 hoursKneeling : Rarely less than 1 hourLifting : Occasionally 1-3 Hours up to 50 lbsPulling : Occasionally 1-3 Hours up to 25 lbsPushing : Occasionally 1-3 Hours up to 25 lbsReaching (Forward) : Rarely less than 1 hour up to 25 lbsReaching (Overhead) : Rarely less than 1 hour up to 25 lbsRepetitive Motions : Occasionally 1-3 HoursSitting : Frequently 3-5 HoursStanding : Occasionally 1-3 HoursStooping : Rarely less than 1 hourTalking : Occasionally 1-3 HoursWalking : Occasionally 1-3 HoursWorking Conditions :
Dusts : Rarely less than 1 hourElectrical : Rarely less than 1 hourInfectious Diseases : Rarely less than 1 hourNoise / Sounds : Rarely less than