Manager Utilization Care Management

Advocate Health•Charlotte, NC

1d•$48 - $71

About The Position

The Manager Utilization Care Management leads the development and oversight of the Utilization Management (UM) program, maintaining department goals and objectives aligned with system strategy, vision, mission, and values. The role evaluates program effectiveness through appropriate metrics, data analysis, reporting, and process improvement. It maintains current knowledge of payer and regulatory requirements and ensures UM policies, procedures, processes, and outcome measures are documented, current, and monitored for compliance and improvement. The manager provides leadership, mentoring, and coaching to direct reports and promotes communication and collaboration across Care Management and partner departments. The position serves as a clinical leader and system resource for UM, supports annual updates to utilization review screening tools and interrater reliability in collaboration with Information Analytics Services, provides ongoing education and competencies, participates in UM Committee activities, and ensures departmental compliance with regulatory standards. The role is full-time, 40 hours per week, with a Monday–Friday schedule of 8:00 a.m.–4:30 p.m.; occasional holidays and weekends are required. The work requires travel or driving between locations and includes physical activity such as walking, standing, lifting, reaching, bending, and stooping. The position requires lifting at least 35 pounds, frequent English verbal and written communication, intact sight and hearing, finger dexterity, critical thinking, concentration, and the ability to respond quickly to changes in assignments. Occasional intermittent noise and exposure to dust, fumes, and chemicals may occur.

Requirements

Master's degree required.
Current RN license or temporary license as a Registered Nurse Practitioner in the applicable state, with the stated National License Compact or non-Compact state requirements.
Two years of related nursing experience required; experience in 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 may qualify.
Appropriate professional certification required within three years of hire per 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 ability to work independently and as part of the care team.
Ability to travel or drive between various locations.
Ability to lift a minimum of 35 pounds and perform walking, standing, lifting, reaching, bending, and stooping.
Frequent verbal and written communication in English; intact sight and hearing, finger dexterity, critical thinking, concentration, and ability to respond quickly to assignment changes.

Nice To Haves

Five years of related nursing experience preferred.

Responsibilities

Manage Utilization Management program development and maintain department goals and objectives aligned with system strategy, vision, mission, and values.
Monitor UM program effectiveness and outcomes by selecting metrics, evaluating data, reporting results, and designing and implementing process improvement projects as needed.
Lead or actively participate in process improvement initiatives involving multiple departments and multidisciplinary staff.
Maintain current knowledge of commercial and government payers and regulatory bodies related to UM activities.
Ensure the UM program maintains documented, current 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 disciplines.
Facilitate, participate in, and oversee annual updates to Utilization Review Screening Tools, including InterQual/Milliman Care Guidelines, and Interrater Reliability in collaboration with Information Analytics Services.
Provide ongoing education and competencies to utilization review nurses, senior utilization review nurses, and other colleagues as desired.
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.