Manager, Utilization Review

Key Responsibilities

• Supervise and mentor a team of Utilization Review Nurses, providing guidance and support to ensure excellent performance.
• Foster a collaborative and cohesive work environment within the department.
• Carry out regular staff meetings, performance evaluations, and staff development activities.
• Oversee the development and implementation of individualized care plans for patients.
• Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.
• Monitor and assess the appropriateness of care plans and resource utilization.
• Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.
• Analyze data and metrics to identify areas for improvement in care coordination processes.
• Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.
• Collaborate with finance and administrative teams to optimize resource utilization.
• Provide ongoing training and education to Utilization Review Nurses to keep them updated on best practices and regulatory changes.
• Encourage professional growth and development within the department.
• Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.
• Participate in complex case reviews and offer guidance on challenging patient cases.
• Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications

• Current RN (Registered Nurse) license. Compact or Multi-State License strongly preferred.
• Bachelor's degree in Nursing (BSN) required, Masters (MSN) preferred.
• Previous experience in case management or care coordination, with at least 2 years in a leadership role.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills.
• Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.
• Proficiency in electronic health records (EHR) and healthcare software.
• Dedication to patient-centered care and a commitment to ethical practice.