Job TitleRegional Manager Utilization Management

                         

LocationCleveland

                    

FacilityRemote Location

                     

DepartmentCare Management Nursing Institute-Nursing Institute

                      

Job Code000973

                     

ShiftDays

                       

Schedule8:00am-4:30pm

                       

Job Summary

                         

Job Details

As the Regional Manager of Utilization Management for Cleveland Clinic Florida, including Indian River, Martin Health, and Weston Hospitals, you will oversee the daily operations of Utilization Management across the region. In this role, you will manage concurrent and retrospective reviews for medical necessity, collaborate with interdisciplinary healthcare teams, monitor utilization outcomes, and lead performance improvement initiatives. You will provide leadership and oversight to Utilization Specialists while ensuring compliance with nationally recognized screening criteria, regulatory requirements, and evolving reimbursement trends. Working closely with Utilization Management Physician Advisors and regional leadership, you will identify opportunities to enhance operational effectiveness, patient outcomes, and resource utilization through the development and implementation of strategic projects and process improvements.

A caregiver in this role works remotely from 8:00 a.m. -- 4:30 p.m. with weekend and holiday coverage requirements and occasional travel to Cleveland Clinic sites for meetings.

To be considered for this position, caregivers must reside within one hour of a Cleveland Clinic hospital in Ohio or Florida.

A caregiver who excels in this role will:

For the Florida region –CC Indian River, CC Martin North, CC Martin South, CC Tradition and CC Weston Hospitals:

• Manage the daily operations of Utilization Management, which includes concurrent and retrospective utilization review for medical necessity, collaboration and participation with the health care delivery team, review of utilization outcomes and related improvement activities.

• Participate in departmental cost budgets and cost containment efforts.

• Review and interpret patient population specific financial reports.

• Recommend/implement resource utilization.

• Prioritize and organize work to meet changing priorities.

• Assist Senior Director as needed.

• Oversee UM Specialists work load and projects.

• Work independently to resolve issues within Utilization Management.

• Utilize independent judgment to identify opportunities for improvement and coordinate projects to attain goals.

• Provide direction and oversight for the UM Specialists daily activities and complete performance evaluations annually.

• Hire and implement disciplinary action when needed.

• Solve complex issues within Utilization Management and report results effectively using evidence-based practice framework.

• Develop, recommend and initiate corrective action to avoid denials.

• Analyze complex data sets to improve patient quality care/ financial outcomes.

• Other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• Bachelor's degree in Nursing, Healthcare Administration or Business Administration

• Completion of an accredited Registered Nursing RN Program

• Proficiency with standard office equipment, including copiers, fax machines, personal computers, as well as Microsoft Office and clinical and financial computer systems

• Three years of nursing clinical experience

• Two years of recent Utilization Review/Care Management experience

• One year of healthcare management experience

• Current valid license in the State of Florida as a Registered Nurse (RN)

• Basic Life Support (BLS) through American Heart Association (AHA) or American Red Cross

• Working knowledge of multiple clinical areas, financial and data analysis, reimbursement practices, preadmission and concurrent review practices

• Advanced understanding of payer issues

• Experience with licensing and accreditation standards, regulatory standards, Utilization Review methodology and theory

• Knowledge of multiple data base systems; clinical, financial and registration

• Advanced knowledge of information, data, and project management

• Advanced knowledge of unit operations, performance improvement/utilization management, regulatory and professional standards, evidence-based practice patient safety/risk management, and outcomes management

• Strong clinical nursing experience and clinical judgment

Preferred qualifications for the ideal future caregiver include: 

• Master's degree

• Demonstrated experience in Project Management, Change Management and/or Program Development

• Certified Professional in Utilization Review or Certified Case Manager

• Two years of prior leadership experience in Utilization Management

• Knowledge of appeals and denial management

• Knowledge of medical necessities criteria

Physical Requirements:

• Requires walking, standing, and sitting for long periods of time.

• Requires constant attention to detail, reading of medical records, and meeting deadlines.

• Works in an environment where there is some discomfort due to dust, noise, temperature.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment.