Manager, Utilization Review - Care Coordination Admin - Full Time 8 Hour Days (Exempt) (Non-Union)

The Manager of Utilization Review provides administrative and operational support to the Director of Case Management. The Manager of Utilization Review provides direct supervision to the Utilization Review Specialists, Utilization Management Specialists, Authorization Coordinators, and ancillary staff.

The Manager provides staff support regarding difficult / complex cases. The Manager is accountable for daily department operations, including establishing utilization review processes that conform to evidence-based review expectations, payer expectations, support collaboration with the organization's billing partners, and appeal processes.

This position is responsible for daily team operations, including staffing, assignments, and human resources management.

If you would like to know a bit more about this opportunity, or are considering applying, then please read the following job information.

Essential Duties :

Leadership & Supervision : Manage and mentor a team of RN Utilization Review Specialists, LVN Utilization Management Specialists, Authorization Coordinators, and ancillary staff.

Provide guidance and support in the development of staff skills and competencies, including but not limited to orienting, training, daily staffing and staff assignments.

Conduct performance evaluations and implement development plans for team members. Engage in special projects, research, consultation and teaching in areas of specialty as needed by the hospital.

Provide leadership in quality management and improvement activities, by planning, organizing, coordinating, monitoring and evaluating care and activities provided by personnel.

• Clinical Review Oversight : Supervise the clinical review process to ensure reviews are conducted accurately and in line with evidence-based guidelines.
• Develop and implement standards and processes for clinical and non-clinical services provided by Utilization Review team members, including organizational planning and program development for needed services.

Utilize advanced theoretical knowledge and skills to act as a consultant to the staff and to the administrative team. Collaborate with clinical teams within Care Coordination to resolve complex cases and ensure authorizations of appropriate care levels.

Formulate and implement policies and procedures related to areas of management, and provide feedback and statistics to hospital administration regarding areas of oversight.

Maintain competencies for hospital, age-specific, and job-specific standards of care, following hospital procedures for accurate and timely processing of charges.

Appeals Management : Develop and implement standards and processes for the formulation and submission of appeal requests for denied services, ensuring they are complete, accurate, and submitted in a timely manner.

Analyze trends in denied claims and collaborate with internal and external partners to address and rectify identified issues.

Regulatory Compliance : Ensure that all processes comply with relevant healthcare regulations, accreditation standards, and organizational policies.

Stay updated on industry standards and changes in regulations to maintain compliance. Incorporate legal and ethical standards into all aspects of Utilization Review processes.

Process Improvement : Identify and implement process improvements to enhance the efficiency, effectiveness, and outcomes of the Utilization Review team.

Develop and maintain departmental policies and procedures. Participate in the development, monitoring and analysis of process and outcome indicators for the improvement of patient care.

Reporting and Analytics : Generate and analyze reports related to utilization review activities and appeal outcomes. Use data to drive decision-making and to identify opportunities for improvement.

Prepare and present reports reflective of utilization review activities and appeal outcomes to department meetings, UM Committee meetings, and other committee meetings upon request.

Performs other duties as assigned.

Required Qualifications :

• Req Bachelors Degree in Nursing
• Req 3-5 years of clinical experience with an additional five years of experience in hospital-based utilization review.
• Req 2 years of consecutive experience in Utilization Review leadership in a manager or above capacity.
• Req Strong leadership and team management skills.
• Req In-depth knowledge of clinical review and appeal processes and healthcare regulations.
• Req Excellent analytical, problem-solving, and decision-making abilities.
• Req Ability to work independently with minimal supervision, exercising judgment and initiative.
• Req Ability to perform a variety of complex and administrative duties and manage conceptual assignments.
• Req Effective communication and interpersonal skills.
• Req Demonstrates ability to effectively work with physicians, staff, and patients.
• Req Committed to excellence in patient care and customer service.

Preferred Qualifications :

• Pref Certified Case Manager - CCM (CMSA) Nationally recognized certification such as CCM and / or ACM
• Pref Proficiency in utilizing healthcare management software and data analysis tools.

Required Licenses / Certifications :

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association

Req Fire Life Safety Training (LA City). If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date.

Required within LA City only)

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