What are the responsibilities and job description for the Manager, Utilization Review position at Witham Health Services?
Job Summary
The Utilization Review Manager is responsible for ensuring that hospital admissions, services, and length of stays meet clinical criteria and are in compliance with healthcare regulations and payer requirements. This position involves performing concurrent and retrospective reviews of patient charts, coordinating with medical staff, insurance companies, and hospital leadership to manage inpatient care effectively while optimizing patient outcomes, minimizing unnecessary admissions, and ensuring appropriate use of healthcare resources. Additionally, the role includes managing insurance denials by identifying issues, working with clinical teams and payers, and facilitating the appeals process.
Minimum Requirements
The Utilization Review Manager is responsible for ensuring that hospital admissions, services, and length of stays meet clinical criteria and are in compliance with healthcare regulations and payer requirements. This position involves performing concurrent and retrospective reviews of patient charts, coordinating with medical staff, insurance companies, and hospital leadership to manage inpatient care effectively while optimizing patient outcomes, minimizing unnecessary admissions, and ensuring appropriate use of healthcare resources. Additionally, the role includes managing insurance denials by identifying issues, working with clinical teams and payers, and facilitating the appeals process.
Minimum Requirements
- Bachelor’s degree in Nursing, Healthcare Administration, or a related field required; Master’s preferred.
- Current Registered Nurse (RN) licensure or clinical background is preferred.
- Certification in Utilization Review (CPUR, CPHQ, or similar) preferred.
- Minimum of 2-3 years of experience in utilization review, case management, or healthcare administration.
- Strong knowledge of medical terminology, inpatient care processes, payer regulations, and denial management.
- Familiarity with healthcare compliance regulations (CMS, Joint Commission).
- Proficiency in using electronic health records (EHR) systems and utilization review software.
- Strong analytical skills with attention to detail.
- Excellent communication and interpersonal skills.
- Ability to work independently and as part of a collaborative healthcare team.
