Utilization Review RN Manager

Location: Yuma Medical Center | Regular full-time, 80 hours every two weeks | Day shift

Pay

Annual salary range: $100,495.83 – $160,793.32 (midpoint $130,644.58). Actual salaries vary based on skills and experience. This range is the base hiring salary and is one component of the total rewards package.

Summary

Under the supervision of the Director of Care Management, the UR RN Manager is responsible for the operational leadership, oversight, and performance of the hospital’s Utilization Review program. This position ensures compliance with federal and state regulations, accreditation standards, payer requirements, and organizational policies related to medical necessity, level of care determination, admission status, prior authorization, and denial prevention. The UR RN Manager provides leadership to Utilization Review and Denials Nurses to ensure appropriate patient status, timely medical necessity reviews, effective physician communication, and accurate reimbursement while supporting high-quality patient care. The manager develops staff, monitors key performance indicators, and leads performance improvement initiatives, collaborating with Revenue Cycle, Clinical Documentation Integrity (CDI), Quality, Compliance, and physician leadership.

Responsibilities

• Provides leadership, oversight, and daily operational management for the Utilization Management Department.
• Supervises, coaches, mentors, and evaluates Utilization Review Nurses and Denials Management staff to promote professional growth and high performance.
• Ensures appropriate staffing levels, workload distribution, and productivity standards to meet departmental and organizational goals.
• Establishes performance expectations and accountability measures that support quality, efficiency, and regulatory compliance.
• Promotes a culture of collaboration, service excellence, employee engagement, and continuous improvement.
• Participates in departmental budget planning, resource allocation, and operational decision-making.
• Supports recruitment, onboarding, orientation, and ongoing competency validation of department staff.
• Provides oversight of admission status determinations, medical necessity reviews, observation services, continued stay reviews, and denial management activities.
• Ensures timely and accurate utilization review processes that support appropriate patient status assignment and reimbursement.
• Oversees escalation processes for complex utilization management cases and payer disputes.
• Collaborates with Physician Advisors, medical staff, Case Management, and Revenue Integrity teams to ensure appropriate level-of-care determinations.
• Monitors trends related to observation utilization, inpatient status conversions, authorization requirements, avoidable delays, and denials.
• Develops and implements strategies to reduce preventable denials and improve reimbursement outcomes.
• Ensures departmental compliance with all applicable federal, state, and accreditation standards governing utilization management activities.
• Maintains knowledge of CMS Conditions of Participation, Medicare regulations, Medicaid requirements, payer-specific guidelines, and hospital-issued notices.
• Oversees processes related to patient status notifications, beneficiary notices, and documentation requirements.
• Ensures utilization management practices align with organizational policies and regulatory expectations.
• Serves as a resource to leadership and staff regarding regulatory changes and compliance requirements.
• Coordinates audits, monitoring activities, and corrective action plans when compliance concerns are identified.
• Serves as a subject matter expert and resource for physicians, advanced practice providers, case managers, revenue cycle staff, and organizational leadership.
• Collaborates with Physician Advisors and medical staff to support appropriate documentation, status determinations, and medical necessity compliance.
• Facilitates effective communication between clinical departments, payers, utilization review staff, and executive leadership.
• Supports physician education initiatives related to regulatory requirements, admission status, documentation, and utilization management best practices.
• Oversees denial prevention, denial management, appeal processes, and recovery efforts.
• Identifies trends affecting reimbursement and develops action plans to improve financial performance.
• Collaborates with Revenue Cycle, Patient Financial Services, and Contracting departments to resolve reimbursement issues and address payer concerns.
• Reviews denial data and appeal outcomes to identify opportunities for education, process improvement, and risk mitigation.
• Supports organizational efforts to optimize reimbursement while maintaining regulatory compliance and quality patient care.
• Leads strategic planning and process improvement initiatives related to utilization management operations.
• Identifies key performance indicators and establishes monitoring processes to evaluate departmental effectiveness.
• Analyzes utilization management, denial, reimbursement, and compliance data to identify improvement opportunities.
• Develops and implements corrective action plans to address performance gaps and operational inefficiencies.
• Supports organizational initiatives related to length of stay management, patient throughput, care progression, and readmission reduction.
• Provides regular reporting of departmental outcomes, trends, and opportunities to senior leadership.
• Ensures staff maintain current knowledge of utilization management practices, payer requirements, regulatory changes, and industry standards.
• Provides ongoing education, coaching, and competency development for Utilization Review and Denials staff.
• Promotes evidence-based utilization management practices and professional certification.
• Supports staff participation in educational and professional development activities.
• Ensures accurate, timely, and compliant documentation of utilization review activities and departmental records.
• Maintains strict confidentiality of patient, provider, and organizational information in accordance with HIPAA and organizational policies.
• Monitors documentation practices to ensure consistency, completeness, and regulatory compliance.
• Participates in organizational committees, regulatory surveys, audits, and accreditation activities as assigned.
• Represents the Utilization Management Department in interdisciplinary meetings and organizational initiatives.
• Performs other duties and responsibilities as assigned by the Director of Case Management or designated leadership.

Requirements

• 3+ years of related experience in Hospital Utilization Management
• Bachelor’s Degree in Nursing
• Active Arizona RN License
• Basic Life Support (BLS) certification (AHA)

About the Organization

Yuma Regional Medical Center, part of Onvida Health, offers a rewarding career where you can make a meaningful difference in the lives of the community. Onvida Health is committed to innovation, kindness, and integrity, fostering a culture of collaboration and continuous improvement. Located in Yuma, Arizona—recognized as the Sunniest City on Earth—you’ll enjoy a welcoming community, outdoor adventures, and a fulfilling work-life balance.