Manager Utilization Care Management

Advocate Health and Hospitals Corporation • Charlotte, NC

1d

About The Position

The Manager of Utilization Care Management leads the development and oversight of the Utilization Management (UM) program, ensuring departmental goals and objectives align with system strategy, vision, mission, and values. The role monitors program outcomes using appropriate metrics, reports results to relevant audiences, and designs or implements process improvements as needed. It also maintains current knowledge of commercial and government payers and regulatory bodies, and ensures UM policies, procedures, and outcome measures remain current and support compliance and improvement.

The manager provides leadership, mentoring, and coaching to direct reports and promotes communication and collaboration across Care Management and related clinical, billing, coding, compliance, and analytics teams. The role oversees updates to utilization review screening tools and interrater reliability in collaboration with Information Analytics Services, supports education and competency development, participates in UM Committee activities, and serves as a clinical leader and system resource for UM expertise. The position is full time, with a Monday–Friday schedule of 8:00 a.m.–4:30 p.m. and occasional holidays and weekends. The listed pay range is $47.50–$71.25.

Requirements

• Master's degree required.
• Current RN license or temporary license as a Registered Nurse Practitioner in the state where the employee works and resides; applicable home-state licensure requirements apply for National License Compact residents.
• Two years of related nursing experience required.
• Appropriate professional certification required within three years of hire, according to Clinical Care Management Certification Guidelines.
• Clinical competence and critical thinking in disease management and case management principles.
• Excellent interpersonal communication and negotiation skills.
• Problem-solving skills, strong organizational and time-management skills, and the ability to work independently and as a member of the care team.
• Ability to travel or drive between various locations.
• Ability to lift a minimum of 35 pounds.
• Frequent verbal and written communication in English.

Nice To Haves

• Five years of related nursing experience preferred.
• Related experience may include case management, discharge planning, utilization management, denial management, or medical necessity review in acute care, home care, long-term care, a physician office, or an insurance plan.

Responsibilities

• Manage development of the Utilization Management program and maintain department goals and objectives aligned with system strategy, vision, mission, and values.
• Monitor UM program effectiveness and outcomes by selecting and applying metrics, evaluating data, reporting results, and designing and implementing process improvement projects.
• Lead or participate in process improvement initiatives with departments and multidisciplinary staff.
• Maintain current knowledge of commercial and government payers and regulatory bodies relevant to UM activities.
• Ensure the UM program has documented, up-to-date policies and procedures and that key processes have valid outcome measures monitored for compliance and improvement.
• Provide leadership, mentoring, and coaching to direct reports.
• Promote communication and collaboration among Care Management, Physician Advisors, Hospital Billing, Coding, Corporate Compliance, Information Analytics Services, and other relevant disciplines.
• Facilitate, participate in, and oversee annual updates of Utilization Review Screening Tools, such as InterQual or Milliman Care Guidelines, and interrater reliability in collaboration with Information Analytics Services.
• Provide ongoing education and competencies for utilization review nurses, senior utilization review nurses, and other colleagues as appropriate.
• Participate in the UM Committee and other UM activities.
• Serve as a clinical leader and system resource for UM expertise.
• Ensure departmental compliance with regulatory standards.

Benefits

• Paid Time Off programs
• Medical, dental, vision, life, and short- and long-term disability benefits
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Adoption assistance
• Paid parental leave
• Defined contribution retirement plans with employer match
• Financial wellness programs
• Educational Assistance Program
• Potential premium pay, incentive pay for select positions, and annual performance-based increases

What This Job Offers

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