Manager Registered Nurse - Utilization Management

SSM Health • MO-REMOTE, MO

6d • Remote

About The Position

This role is more than a career, it's a calling. The Manager of RN Utilization Management will lead a team dedicated to delivering high-quality, cost-effective patient care. This position combines clinical expertise with strategic leadership to oversee care coordination, utilization review, and regulatory compliance initiatives, helping ensure patients receive the right care at the right time while driving exceptional outcomes across the continuum of care. The position is fully remote, and candidates must reside in MO, OK, IL, or WI. Preference is given to candidates located in the St. Louis region. Standard work hours are Monday through Friday, 8:00 a.m. to 4:30 p.m., with occasional weekend support required for managing weekend staff.

Requirements

• Extensive Utilization Management experience or Case Management experience.
• Strong understanding of CMS, Medicare & Medicaid, and Commercial regulations.
• Experience leading large cross-functional teams at a management level.
• Experience leading denials and appeals resolutions.
• Experience analyzing denial, authorization, and utilization data to identify trends, opportunities, and areas for improvement.
• Ability to embrace change and promote continuous improvement.
• Effective leadership through evolving priorities and organizational initiatives.
• Ability to foster a culture of accountability, collaboration, adaptability, and engagement.
• Ability to serve as a trusted partner to staff, physicians, and operational leaders.
• Bachelor's degree in nursing
• Two years' acute nursing registered nurse experience and five years' utilization management experience, with two years' of demonstrated progressive leadership experience
• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Registered Nurse (RN) Issued by Compact State or Registered Nurse (RN) - Missouri Division of Professional Registration
• Registered Nurse (RN) Issued by Compact State or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
• Registered Nurse (RN) Issued by Compact State or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Responsibilities

• Responsible for department operations, which includes referrals, medical necessity and experimental/investigational reviews, and application of medical policies and business processes.
• Ensures the quality and accuracy of Utilization Management (UM) review decisions, and the adherence to UM and Care Management departmental policies.
• Participates in the development of policies and oversee staff activities to ensure compliance with regulatory and accrediting standards.
• Oversees staffing and productivity and adjusts staffing patterns to provide adequate coverage for UM operations during absences and vacancies.
• Monitors and adheres to budget. Approves or monitors expenditures, purchases, and other actions to ensure compliance with budget guidelines.
• Ensures that the UM team meets performance metrics and work plan requirements.
• Represents UM in the participation on committees, task forces, work groups and multidisciplinary teams, as assigned.
• Assists with the development, maintenance, and adherence of UM programs and processes.
• Assists and participates in meeting company and department goals such as quality improvement activities.
• Recruits, engages, develops, leads, and manages assigned staff.
• Performs other duties as assigned.

Benefits

• One week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Instant access to earned, unpaid base pay before payday through DailyPay (fees may apply).
• Upfront tuition coverage through FlexPath Funded for eligible team members.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager