Manager of Utilization Review

Leads all Utilization Management (UM) activities for all observation, surgical and inpatients of the hospital. Facilitates safe, high-quality, and cost-effective patient care, and directs the daily operations of the utilization review department. Provides oversight, strategic direction and creation of the utilization review plan, coordination of denial management activities, and analyzes patient utilization and financial data to continuously improve outcomes (patient care workflows and data/reporting systems). Provides leadership and direction to the Physician Advisor, Utilization Review Nurses, and Denial Coordinator, with continuous UM education that minimizes denials, promotes cost containment strategies, and keeps current with rapidly changing medical necessity criteria. Essential member of a multidisciplinary team that implements new projects across the continuum of care and works collaboratively with internal staff, external partners, and physician leaders. Significant contributor to the Utilization Review Committee and the Utilization Review Plan.

• Current Maryland RN license or current RN license in compact state of primary residence.
• Certification in Case Management (CCM or ACM) preferred

• Oversees the workload and assignments of all staff involved in the utilization management process for patients.
• Demonstrates knowledge of reimbursement mechanisms.
• Oversee efficient and productive use of time to ensure payers receive clinical updates per contractual obligations to support the organization’s length of stay and budget goals.
• Leads process improvement initiatives across the system related to utilization management.
• Demonstrates leadership and effective communication skills when collaborating with all departments, disciplines, and staff on
• issues related to quality, cost-effective patient care, and length of stay.
• Responsible for daily coordination and supervision of the utilization review process.
• Manages scheduling, staffing, and daily assignment of staff.
• Ensures timely and complete documentation of clinical reviews and peer-to-peer discussions within the department
• Maintains effective communication with patients, families, physicians, referral sources, payers, and other hospital departments to facilitate delivery of quality services.
• Adheres to budgetary guidelines.
• Ensures staff adherence to established productivity standards.
• Maintains an acceptable denial rate by ensuring staff adhere to the following: effective peer-to-peer discussions, daily level of care verification, UR completion and clinical submission per payer contracts, and effective collaboration with providers and
• billing office teams.
• Serves as subject matter expert of InterQual criteria, payer guidelines and contract owner for InterQual software.
• Develops departmental policies and IT system updates to support utilization management functions and practices.
• Facilitate, trend, and analyze utilization review data to present to the Utilization Review Committee, physician leaders, and senior leaders for purposes of performance improvement, trend analysis, and strategic planning.
• Reviews all patients with extended LOS daily to optimize the use of acute care services. Participates in multi-disciplinary care conferences
• with leaders and department managers to identify ways to reduce the LOS.
• Facilitates staff development through observation and evaluation.
• Identifies opportunities for improvement; plans, develops, and implements individual staff and department action plans.
• Provides individualized staff recognition for professional and educational accomplishments.
• Conducts introductory and annual evaluations of all staff within the department.
• Maintains staff personnel files.
• Schedules and conducts staff meetings on a regular basis.
• Supports staff via managerial rounding.
• Develop team building skills and programs recognizing and directing individuals including incentive plans, goals, and objectives
• Maintains accurate and current knowledge of clinical criteria guidelines, payer practices, and regulations.
• Responsible for continuing the education of the utilization review team, physician leaders, and multidisciplinary leaders regarding Inpatient/Observation status, medical necessity protocols, utilization management, documentation standards, and state
• and federal regulatory updates.
• Maintains collaboration with Patient Financial Services leaders to identify process improvement work regarding authorization, payer practices, and denial prevention.
• Provides updates to Executive Directors, and physician leaders, of all clinically complex, and financially weighty cases, offering possible solutions through discussion and feedback.
• Represents the department by serving on several health system-wide committees.

• Develops, implements, and ensures achievement of short- and long-term strategic goals.
• Actively participates in program development

• Manages and oversees the budget of assigned areas.
• Develops operating budget and makes recommendations with appropriate Hospital staff.
• Maintains inventory and analyzes cost of supplies and services.
• Ensures accounts payable issues are managed appropriately.
• Processes payroll for assigned areas.

• Manages human resources within established productivity guidelines and the personnel budget.
• Facilitates training and development efforts. § Maintains employee competencies.
• Monitors and reviews work performance of staff.
• Responsible for interviews and selection of personnel.
• Plans and designs staffing patterns and staffing mixes.
• Empowers and encourages staff to function independently.
• Oversee the appraisals, formal and informal of all staff in the UR department.
• Oversee tracking and trending of productivity and quality.

• Monitors, investigates, and responds to customer feedback, modifying systems/processes as needed.
• Emphasizes patient satisfaction and works with physicians and staff within their assigned clinical/ancillary services to increase
• awareness and develop a culture emphasizing patient focused care and patient satisfaction.
• Recognizes the role of insurers and the importance of their relationship to their assigned operations.
• Facilitates development of clinical protocols, critical pathways, and utilization practices and protocols.

• Maintains standards to meet all regulatory and review agency requirements.
• Oversees staff involvement in quality control and improvement efforts, general safety, and infection control procedures.
• Participates in interdisciplinary unit quality improvement processes and the development of outcome measurements for care
• delivered within their assigned clinical/ancillary services.

• Performs ongoing education to enhance management skills.

$81,255.55 - $135,204.11