OverviewThe Manager of Utilization Review provides operational leadership and oversight for utilization review activities across the health system. This role is responsible for ensuring clinical appropriateness of patient status determinations, regulatory compliance, medical necessity review processes, denial prevention strategies, and efficient utilization of healthcare resources. The Manager leads a team of Utilization Review Specialists, Nurses, and related staff while partnering closely with physician advisors, case management, care coordination, revenue cycle, compliance, and payer relations teams. The Manager establishes standardized utilization management processes across all facilities, drives performance improvement initiatives, supports regulatory compliance, and ensures accurate inpatient, observation, and outpatient status determinations to optimize reimbursement and reduce avoidable denials. This role aligns with enterprise strategies focused on quality outcomes, efficient resource utilization, and sustainable financial performance. The position supports organizational efforts related to utilization review plans, Condition Code 44 processes, MOON notifications, admission status accuracy, denial prevention, and compliance with CMS Conditions of Participation.
QualificationsEducation- Bachelor's degree in nursing.
- Master's degree in nursing, Healthcare Administration, Business Administration, or related field preferred.
Experience- Minimum five (5) years of Utilization Management, Case Management, Revenue Cycle, or Denials Management experience.
- Minimum three (3) years of leadership experience managing hospital UM operations.
- Experience leading multi-site or enterprise-wide coding operations preferred.
- Experience working with Medicare, Medicaid, and commercial payers.
- Experience analyzing denial and authorization data.
- Experience with complex health system or academic medical centers is strongly preferred.
- Epic experience a must.
- Knowledge of claims processing, denials management, and reimbursement analysis.
- Ability to interpret regulatory requirements and translate them into operational processes.
- Ability to manage multiple priorities and lead through organizational change.
License/Certification/Registration- Registered Nurse (RN) required.
- Prior Authorization Certified Specialist (PACS) preferred.
- Accredited Case Manager - Registered Nurse (ACM-RN) preferred.
- Certified Case Manager (CCM) preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Certification in Healthcare Quality and Management (HCQM) preferred.
- Certified Professional in Utilization Review (CPUR) preferred.
- Clinical Medical Assistant Certification (CMAC) preferred.
- Certified Revenue Cycle Representative (CRCR) preferred.
