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
Inpatient care plans and reimbursement workflows
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
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, clinical documentation improvement tools
Responsibilities
Perform concurrent and retrospective medical necessity reviews; manage denial appeals and audits; educate physicians and staff on documentation standards; coordinate discharge planning and care transitions; analyze statistical data to identify process improvements; serve as Co-Chairperson of the Utilization Review Committee.
Seniority
Senior, hands-on IC with management responsibilities
