Manager, Utilization Management

Day (United States of America)

900 HOPE WAY

ALTAMONTE SPRINGS

Florida

32714

Provide operational oversight for utilization review and hospital authorizations. Manage staff performance, discipline, evaluation and termination. Utilize clinical assessment knowledge and critical thinking skills to lead the team and enhance outcomes. Champion implementation of practice changes and serve as a supportive change agent. Collaborate with various departments to address authorization and medical necessity concerns. Contribute to policy formulation and decision-making using knowledge of Utilization Management standards and government and contractual guidelines. Build relationships to promote interdisciplinary collaboration. Evaluate the efficiency, clinical appropriateness, and necessity of medical services and procedures in the most resourceful clinical setting. Other duties as assigned.Knowledge, Skills, and Abilities:
• Current knowledge of utilization/denial management key accountabilities to engage in development and implementation of education and training of key initiatives. [Required]
• Capacity and desire to lead others; ability to manage fast-paced, multi-faceted environment and maintain service standards. [Required]
• Provide education and detailed instructions regarding workflows and strategic initiatives to varied groups of adult learners in various settings. [Required]
• Expertise in medical necessity screening determinations and status recommendations. [Required]
• Expertise in EMR systems, primarily in utilization review/denial management and roles and responsibilities of various disciplines. [Required]
• Ability to navigate and utilize other related software and databases for educating new system end-users. [Required]
• Demonstrates strong analytical, problem solves skills and the ability to analyze complex data. [Required]
• Proficiency in use of spreadsheets and report software. [Required]
• Proficient in using multiple computer applications interchangeably. [Required]
• Communicates professionally with an acceptable use of English (speaking, reading, and writing). [Required]
• Knowledge of payer guidelines, reimbursement methodologies, and appeals processes and their impact. [Preferred]
• Ability to execute Excel spreadsheets and Power Point presentations. [Preferred]
• Ability to present information in written and presentation form to various Executive Leaders. [Preferred]
• Overall understanding of payer contracts and government/regulatory compliance. [Preferred]
• Working knowledge of RAC (Recovery Audit Contractor) Manager Program (RM). [Preferred]

Education:
• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]

Field of Study:
• N/A

Work Experience:
• 2+ utilization management or case management [Required]
• 3+ clinical nursing experience [Required]
• 5+ clinical nursing in an acute care setting [Preferred]
• Experience working in electronic health records [Preferred]
• Precepting, People Leader, or Informal Leader (i.e., charge nurse, team lead, etc.) [Required]
• Supervisor in a Utilization Management or Case Management department [Preferred]

Additional Information:
• N/A

Licenses and Certifications:
• Registered Nurse (RN) [Required] AND
• Accredited Case Manager (ACM) [Preferred] OR
• Certified Case Manager (CCM) [Preferred]

Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/msy4mja2

$79,402.93 - $147,697.47