Job Description: RN Manager Utilization ReviewAbout the Job: Under the direction of the Director of Care Coordination, the Manager of Utilization Review provides strategic, operational, and clinical leadership for the Utilization Review (UR) function. This role is accountable for program performance, regulatory compliance, denial mitigation outcomes, staff development, and financial stewardship related to utilization management activities. The Manager ensures consistent application of level-of-care criteria, high-quality clinical documentation, timely and accurate payer communication, and integration of utilization review with broader care coordination and organizational goals. This position partners extensively with physician leadership, revenue cycle, quality, compliance, and external payers to optimize patient outcomes and appropriate resource utilization.
What You'll Do:- Provider leadership and oversight of the utilization review staff and operations to ensure accurate, timely, and
- compliant level-of-care determinations and clinical submissions.
- Provides second-level review and clinical escalation support, including complex cases, denials, and appeals.
- Ensures consistent application of InterQual (or equivalent) criteria and promotes best practices in clinical
- documentation.
- Directs and monitors denial prevention and mitigation strategies, tracking trends and implementing corrective
- action plans.
- Maintains accountability for utilization performance indicators, including denial rates, appeal success, length
- of stay, and financial impact.
- Partners with finance and revenue cycle leaders to understand payer trends and guide strategies that support
- organizational financial health.
- Ensures compliance with CMS Conditions of Participation, payer contracts, accreditation standards, and
- hospital policies.
- Actively participates in, Utilization Management Oversight Committees, audits, and regulatory reviews.
- Builds and maintains strong working relationships with physicians, nursing leadership, case management,
- quality, compliance, and external payers.
- Leads data-driven quality improvement initiatives related to utilization management and care coordination
- outcomes.
- Identifies process inefficiencies and champions innovative solutions to improve patient flow, documentation
- quality, and payer communication.
- Promotes a learning environment through education, competency development, and evidence-based practice
- updates.
- Employees are expected to work consistently to demonstrate the mission, vision, beliefs, core values and
- standards of behavior of the organization.
Who You Are: - Graduate of an accredited nursing program- Bachelor's degree in Nursing or higher Nursing degree required. Masters preferred
- Managerial experience preferred. Demonstrated knowledge of Utilization Review and InterQual Required. Denials Management, case management, utilization performance outcomes
- Leadership and people management skills. Comprehensive knowledge of utilization management practices, including medical necessity determination, level of-care criteria (InterQual), denial prevention, and appeal processes across payers Clinical decision-making skills, Communication and relationship building, Analytical skills, Process Improvement
- Active New Hampshire or Compact State RN license required.
- CCM or ACM certification preferred.
Why You'll Love Us:- Health, dental, prescription, and vision coverage for full-time & part-time employees
- Short-term, long-term disability, life & pet insurance
- Tuition reimbursement
- 403(b) Retirement savings plans
- Continuous earned time accrual
Work Shift: 1st Shift
