Manager Utilization Management & Clinical Appeals
About The Position
Under the general direction of the Director of Utilization Management, the Manager provides leadership for utilization management nurses, payor liaison/utilization management specialists, and preauthorization staff assigned to the utilization management department. The role participates in designing, developing, implementing, and improving Brown University Health’s utilization management model and fosters patient- and family-centered care in accordance with the organization’s mission, vision, and values. The position is expected to role model Brown University Health’s values of Compassion, Accountability, Respect, and Excellence, and demonstrate core success factors including instilling trust, valuing differences, patient and community focus, and collaboration. Leaders are also expected to ensure accountability, build effective teams, drive vision and purpose, and optimize work processes. The manager oversees staff development and performance, departmental policies and strategic plans, institutional priorities, budgets, and resource allocation. The role includes serving as a rotating on-call resource to system utilization management nurses on weekends and holidays. The position is based at Rhode Island Hospital in Providence, Rhode Island, and is listed as a day-shift, Monday–Friday role with an 8-hour daily schedule.
Requirements
- Current Registered Nurse license in Rhode Island, or licensure under the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
- Bachelor’s degree in nursing.
- Five years of relevant clinical or utilization management experience with demonstrated leadership skills.
- Strong written and oral communication skills.
- Knowledge of utilization review criteria.
- Understanding of the provisions of the Rhode Island Nurse Practice Act.
Nice To Haves
- Master’s degree in nursing or another health discipline.
- Certification in case management.
- Previous case management or utilization management leadership experience.
Responsibilities
- Lead utilization management nurses, payor liaisons, and preauthorization staff, including orientation, continuing education, and competency assessment.
- Participate in interviewing; recommend staff selections; direct staff activities; and evaluate professional and support staff to support organizational goals and objectives.
- Collaborate with the Director of Utilization Management to develop measures for evaluating staff competencies and orientation.
- Serve as a resource to utilization managers, payor liaisons, and support staff.
- Develop departmental policies and strategic plans.
- Collaborate with the Director of Utilization Management and the Medical Director of Utilization Management to identify institutional needs and determine priorities.
- Develop, analyze, and adhere to departmental, capital, and operating budgets, ensuring appropriate staffing and resources to support utilization management standards of practice.
- Ensure effective use of people, financial, material, and equipment resources to meet established goals and objectives.
- Serve as a rotating weekend and holiday on-call resource to system utilization management nurses.
- Support effective resource utilization, continuous quality improvement, high-quality and high-value patient-focused services, resource productivity, fiscal responsibility, quality program development and implementation, customer satisfaction, year-to-year performance improvement, and positive feedback from peers, direct reports, and staff.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
