Manager – Utilization Management

Manager – Utilization Management

Requirements

• Must have a New York RN license.
• Graduate of an Accredited School of Nursing or Bachelor’s degree required.
• 5+ years of related experience required.
• Knowledge of utilization management principles preferred.

Responsibilities

• Manages prior authorization, concurrent review, and retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures.
• Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives.
• Develops, implements, and maintains compliance with utilization management policies and procedures.
• Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership.
• Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management.
• Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers.
• Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services.
• Works with utilization management senior management team to provide updates and insights on team goals and objectives.
• Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards.
• Assists utilization management senior leadership with onboarding, hiring, and training utilization management team members.
• Leads and champions change within scope of responsibility.
• Performs other duties as assigned.
• Complies with all policies and standards.

Preferred Qualifications

• 2+ years supervisory experience preferred.