Regional Manager Utilization Management

About the role

As the Regional Manager of Utilization Management for Cleveland Clinic Florida, including Indian River, Martin Health, and Weston Hospitals, you will oversee the daily operations of Utilization Management across the region. In this role, you will manage concurrent and retrospective reviews for medical necessity, collaborate with interdisciplinary healthcare teams, monitor utilization outcomes, and lead performance improvement initiatives.

Responsibilities

• Manage the daily operations of Utilization Management, which includes concurrent and retrospective utilization review for medical necessity, collaboration and participation with the health care delivery team, review of utilization outcomes and related improvement activities.
• Participate in departmental cost budgets and cost containment efforts.
• Review and interpret patient population specific financial reports.
• Recommend/implement resource utilization.
• Prioritize and organize work to meet changing priorities.
• Assist Senior Director as needed.
• Oversee UM Specialists work load and projects.
• Work independently to resolve issues within Utilization Management.
• Utilize independent judgment to identify opportunities for improvement and coordinate projects to attain goals.
• Provide direction and oversight for the UM Specialists daily activities and complete performance evaluations annually.
• Hire and implement disciplinary action when needed.
• Solve complex issues within Utilization Management and report results effectively using evidence-based practice framework.
• Develop, recommend and initiate corrective action to avoid denials.
• Analyze complex data sets to improve patient quality care/ financial outcomes.

Requirements

• Bachelor's degree in Nursing, Healthcare Administration or Business Administration
• Completion of an accredited Registered Nursing RN Program
• Proficiency with standard office equipment, including copiers, fax machines, personal computers, as well as Microsoft Office and clinical and financial computer systems
• Three years of nursing clinical experience
• Two years of recent Utilization Review/Care Management experience
• One year of healthcare management experience
• Current valid license in the State of Florida as a Registered Nurse (RN)
• Basic Life Support (BLS) through American Heart Association (AHA) or American Red Cross
• Working knowledge of multiple clinical areas, financial and data analysis, reimbursement practices, preadmission and concurrent review practices
• Advanced understanding of payer issues
• Experience with licensing and accreditation standards, regulatory standards, Utilization Review methodology and theory
• Knowledge of multiple data base systems; clinical, financial and registration
• Advanced knowledge of information, data, and project management
• Advanced knowledge of unit operations, performance improvement/utilization management, regulatory and professional standards, evidence-based practice patient safety/risk management, and outcomes management
• Strong clinical nursing experience and clinical judgment

Qualifications

• Master's degree
• Demonstrated experience in Project Management, Change Management and/or Program Development
• Certified Professional in Utilization Review or Certified Case Manager
• Two years of prior leadership experience in Utilization Management
• Knowledge of appeals and denial management
• Knowledge of medical necessities criteria

Skills

• Excellent communication and interpersonal skills
• Strong analytical and problem-solving abilities
• Ability to work independently and prioritize tasks
• Strong organizational and time management skills
• Ability to work collaboratively with interdisciplinary healthcare teams
• Knowledge of healthcare regulations and reimbursement practices
• Ability to analyze complex data sets and make informed decisions

Benefits

• Health Plan Options – You have the choice between two comprehensive Cleveland Clinic Employee Health Plan options: EHP and EHP Plus. Both plans are administered by Aetna and feature minimal copays for in-network care.
• Dental Care – Four plan options administered by Cigna are available.
• Vision Care – Two plan options administered by EyeMed are available.
• Flexible Spending Accounts – Healthcare and Dependent Care FSAs are available to help you pay for eligible expenses with pre-tax dollars.
• Life Insurance – Employer-paid life insurance equals 1x your annual salary with an option to purchase supplemental life insurance up to 10x your salary. You may also purchase dependent life insurance for a spouse and dependent children
• Short- and Long-term Disability Coverage – Short-term disability is available after one continuous year of regular full-time service; long-term disability begins after 90 days.
• Cleveland Clinic Investment Pension Plan offers eligible employees an excellent opportunity to build a retirement account for the future. It is fully funded by Cleveland Clinic and equal to 2.5% of your salary (increasing with more years of service).
• The 401(k) / 403(b) Plan also provides an important source of retirement savings. It allows participants to take responsibility for their financial future by making retirement savings a part of their normal routine while working. In addition to your contributions to the plan, Cleveland Clinic matches a portion of your contributions (50% on up to your first 6% in contributions).
• Paid Time Off (PTO) – Eligible caregivers receive Paid Time Off (PTO) that can be allotted toward vacation, holidays, sick time, etc.
• Caregiver discounts – We offer discounted rates for auto, home and pet insurance, identify theft protection and more.
• Adoption assistance – We provide financial assistance of up to $5,000/per child ($10,000 maximum lifetime benefit) for caregivers who choose to legally adopt a child.
• Employee Assistance Program – The Program provides free, confidential short-term counseling for caregivers and their families, whether for relationships or legal challenges.
• Employee Hardship Fund – This fund provides aid for caregivers experiencing unexpected financial difficulties.
• Paid maternity and parental leave – You will enjoy up to eight consecutive weeks for maternal care after the birth of your child to bond with your baby and up to four weeks for parental care.

Pay

Pay Range
Minimum Annual Salary: $76,540.00
Maximum Annual Salary: $116,747.50

Schedule

Full Time
Shift: Days