What are the responsibilities and job description for the MANAGER OF UTILIZATION REVIEW position at Southwest General?
Summary
Southwest General Health Center is a 352-bed community hospital located in Middleburg Heights, Ohio. One of the last standing community hospitals in Northeast Ohio, we partner with University Hospitals and other local community organizations to provide a full range of services to all who need us. We are certified as a Level III Trauma Center and a Primary Stroke Center, and have been serving our community for over 100 years!
Why work at SWGHC? In addition to the outstanding culture, we offer great benefits, no rotating shifts, free parking and are close to the turnpike and I71. Come join our team! #loveajobthatlovesyouback
Position Summary:
Responsible for the oversight of the organization’s Utilization Review processes and staff. These processes are to include prior authorizations, reviews of documentation for demonstration of clinical need, and coordination/communication with insurers and Managed Care Organizations. This position will work closely with clinical and administrative teams to facilitate the authorization lifecycle and communicate payer requirements. The UR Manager will participate in quality improvement activities and will ensure appropriate tracking/reporting of utilization data across the organization.
Education: Current R.N. licensure by Ohio State Board of Nursing. BSN required.
Required Length and Type of Experience: Minimum of 5 years’ experience in clinical nursing or related nursing field. Minimum of 3 years in current Case Management/Utilization management. Must have knowledge of Medicare/Medicaid and commercial insurance requirements in relation to medical necessity documentation. Must have knowledge of Interqual and MCG criteria. Needs to have basic Word/Excel computer skills. Minimum of 3 years of supervisory experience.
Required Licensure, Certification or Registry: Case Management certification or accreditation preferred.
