Job Summary and ResponsibilitiesAs the Manager of Utilization Management you are responsible for managing day-to-day UM operations within the markets, focusing on effective team management, authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. Every day you will also perform essential duties and responsibilities (utilization reviews, denials, and authorizations) in non-represented markets, with a time allocation of no more than 40% of the total work hours, and oversee a group of Utilization Management staff. To be successful in this role you must ensure a balance between management and operational responsibilities to maintain effective team leadership and oversight. This role supports the Utilization Management Director in ensuring efficient operations with all processes, policies, strategies and ensuring compliance with all regulatory and payer requirements.
Job Requirements
Requirements:
- Bachelors Degree in Nursing, Health Care Administration or related clinical field
- California RN license
- Minimum 5 years of experience with clinical case management (utilization management, denial management or care coordination)
- Minimum of 3 years management experience in a clinical case management department (utilization management, denial management or care coordination)
Preferred
- Masters in Nursing, Health Care Administration or related clinical field
- Experience with DRG, reimbursement pricing and coding processes for inpatient and outpatient services
