Manager, Utilization Managment
Core
Licensed nursing professional managing patient classification, medical necessity reviews, and discharge planning to ensure safe care and appropriate reimbursement.
Role type
Senior Utilization Management Manager (Nursing)
Builds
Patient care plans and financial compliance workflows
Domain
Healthcare / Utilization Management
Required skills
Registered Nurse licensure, inpatient case management, utilization review, staff education, Leveling tools (InterQual), regulatory compliance, data analysis, interdisciplinary collaboration
Preferred skills
Master's in Nursing, leadership experience, change management, system-level workflow design
Technologies
InterQual criteria, PEPPER data, Leveling tools
Responsibilities
Perform concurrent and retrospective medical necessity reviews; manage denial appeals and audits; educate physicians and staff on documentation standards; coordinate discharge planning; analyze statistical data for quality improvement; act as Co-Chairperson of the Utilization Review Committee.
Seniority
Senior, hands-on IC with management responsibilities