Manager, Utilization Management

About the role

Joining AdventHealth is about extending the healing ministry of Christ. You'll be part of a community dedicated to the wholeness of each person, serving them in body, mind, and spirit.

Responsibilities

• Provide operational oversight for utilization review and hospital authorizations.
• Manage staff performance, discipline, evaluation, and termination.
• Lead the team and enhance outcomes through clinical assessment and critical thinking.
• Champion implementation of practice changes and serve as a supportive change agent.
• Collaborate with various departments to address authorization and medical necessity concerns.
• Contribute to policy formulation and decision-making using knowledge of Utilization Management standards and government and contractual guidelines.
• Build relationships to promote interdisciplinary collaboration.
• Evaluate the efficiency, clinical appropriateness, and necessity of medical services and procedures in the most resourceful clinical setting.

Qualifications

• Current knowledge of utilization/denial management key accountabilities.
• Capacity and desire to lead others; ability to manage fast-paced, multi-faceted environment and maintain service standards.
• Expertise in medical necessity screening determinations and status recommendations.
• Expertise in EMR systems, particularly in utilization review/denial management and roles and responsibilities of various disciplines.
• Ability to navigate and utilize other related software and databases for educating new system end-users.
• Demonstrates strong analytical, problem-solving skills and the ability to analyze complex data.
• Proficiency in use of spreadsheets and report software.
• Proficient in using multiple computer applications interchangeably.
• Communicates professionally with an acceptable use of English (speaking, reading, and writing).
• Knowledge of payer guidelines, reimbursement methodologies, and appeals processes and their impact.
• Working knowledge of RAC (Recovery Audit Contractor) Manager Program (RM).

Education

• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]

Field of Study

N/A

Work Experience

• 2+ utilization management or case management [Required]
• 3+ clinical nursing experience [Required]
• 5+ clinical nursing in an acute care setting [Preferred]
• Experience working in electronic health records [Preferred]
• Precepting, People Leader, or Informal Leader (i.e., charge nurse, team lead, etc.) [Required]
• Supervisor in a Utilization Management or Case Management department [Preferred]

Additional Information

N/A

Physical Requirements

View physical requirements here

Pay Range

$79,402.93 - $147,697.47