Manager, Utilization Review

A Brief Overview

The Manager, Utilization Review manages the daily operations of the Utilization Review Department and is responsible for overseeing and coordinating utilization review processes within Regional One Health. Utilization Review activities include inpatient, observation, outpatient in a bed, ambulatory surgery, and Point-of-Entry Utilization review/case management activities. This role is crucial in ensuring appropriate utilization of healthcare resources while maintaining high-quality patient care. The Utilization Review Manager works collaboratively with medical and hospital staff to efficiently support and integrate utilization review activities.

What You Will Do

• Reports to the Sr. Director on department activities, market changes, and operational opportunities, presenting action plans as necessary.
• Establishes and maintains an organizational structure and staffing to meet departmental and organizational goals.
• Develops and implements utilization review policies and procedures in compliance with regulatory requirements and industry best practices.
• Stay current on changes in healthcare regulations, laws, and policies affecting utilization review.
• Supervises the utilization review staff, including case managers (Point of Entry) and the utilization review team.
• Oversees the submission of utilization activities, including ensuring timely and accurate submission of medical necessity reviews, clinical documentation to providers for authorization and concurrent review, and planned surgery authorizations.
• Conducts periodic reviews of medical records to assess the appropriateness of care and services provided.
• Assists in developing and managing department budgets and implementing cost containment measures as needed.
• Participates in quality improvement initiatives, including patient satisfaction surveys and process improvement projects.
• Communicates utilization review findings and recommendations to hospital administration, medical staff, and other stakeholders.
• Ensures compliance with best practices and standards related to utilization review metrics and data collection.
• Oversees staff competencies, training, and development to maintain a highly skilled workforce.
• Supports leadership in setting department goals, monitoring program effectiveness, and making necessary adjustments based on utilization statistics and cost-benefit analysis.
• Leads quality improvement initiatives, including audits and mock inspections, to maintain compliance and operational excellence.
• Ensures timely submission of departmental reports, highlighting findings, recommendations, and action plans.
• Encourages professional growth and continuous education among team members.
  
  

Qualifications

• Bachelor's Degree in Healthcare Administration or Management Preferred
• Bachelor's Degree in Nursing (BSN) Preferred
• Master's Degree Strongly preferred
• Registered Nurse (RN) Required
• Minimum 5 years experience Five (5) years’ progressively responsible related experience is required, preferably within a healthcare environment. Required
  
  

Physical Demands

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Constantly
• Lifting - Rarely
• Carrying - Rarely
• Pushing - Rarely
• Pulling - Rarely
• Climbing - Rarely
• Balancing - Rarely
• Stooping - Rarely
• Kneeling - Rarely
• Crouching - Rarely
• Crawling - Rarely
• Reaching - Rarely
• Handling - Occasionally
• Grasping - Occasionally
• Feeling - Rarely
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Frequently
• Eye/Hand/Foot Coordination - Frequently
  
  

Regional One Health is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.