Nurse Manager - Utilization Management

Nurse Manager - Utilization Management (onsite role)

Anne Arundel Medical Center, Annapolis, MD

Full Time - Day shift (Monday - Friday)

Department:    Care Management

Reports To:      Sr Director of Care Management and Transitional Care

FLSA Status:     Exempt

Position Objective:  

The Utilization Management (UM) Manager leads utilization review activities and the daily activities of the UR team. This role provides direct supervision of utilization review staff and functions at Luminis Health.  This role is expected to provide expert knowledge regarding medical necessity and level of care determinations, payer requirements, and CMS regulatory guidelines. This position requires a strong collaboration with the physician advisors and hospital medical staff.  UM Manager will support policies and procedures, education and staff development, and designated management functions to promote high-quality, cost-effective health care that incorporates best practices and ensures effective utilization review.

Essential Job Duties:

1. Staff Acquisition and Support: Recruits, orients and assigns staff for caseload responsibilities. Provides guidance for staff performance, including evaluation, orientation, and maintaining competency requirements, offering feedback, and implementing disciplinary measures as needed.
2. Team Guidance and Leadership: Organizes and leads team meetings, providing education on access management, observation, medical necessity, and CMS guidelines. Regularly offers performance feedback and strategic outcome measures to leadership.
3. Performance Tracking and Improvement: Tracks, analyzes, and implements strategies to improve team performance based on utilization trends and identifies performance indicators, initiating monitoring and process improvements.
4. Compliance and Regulatory Oversight: Demonstrates knowledge of regulatory and accreditation requirements, ensuring compliance with Maryland state law, Medicare, Medicaid, and third-party payer standards. Oversees completion of utilization reviews in accordance with relevant policies.
5. Interdisciplinary Collaboration: Ensures collaboration among healthcare team members regarding capacity and resource decisions, frequently collaborating as a resource for physicians, nurses, and other healthcare professionals.
6. Professional Judgement in Utilization Review: Employs sound professional judgment to evaluate severity of illness and intensity of services, escalating cases as necessary to payers, physician advisors, leadership, or the medical team.
7. Physician Advisor Relationship: Works closely with employed physician advisors to support decision-making and adherence to care standards.
8. On-site Review Preparation: Assists in preparation for on-site reviews by outside review organizations and ensures readiness for external evaluations.
9. Standards of Care Compliance Monitoring: Monitors compliance with standards of care through observation and documentation, communicating results and implementing corrective actions to address deficiencies.
10. Contract and Resource Management: Understands contract language requirements, providing guidance to teams, and ensures appropriate management of resource use within established guidelines.

 Educational/Experience Requirements:

• BSN is required.
• 2 years Utilization Management experience required; hospital experience desired.
• 1 year of managerial experience preferred.
• Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines (MCG) preferred.

RequiredLicense/Certifications:

• Current RN license from Maryland Board of Nursing.
• CCM or ACM certification preferred 

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

_{Medium work. Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.}

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.