Manger Utilization Management & Quality, Peace Hosptial

UofL Health•Louisville, KY

7d•Onsite

About The Position

The Manager of Utilization Management (UM) leads the strategic and operational oversight of utilization review and management across the academic healthcare system. This role ensures appropriate resource utilization, regulatory compliance, and alignment with clinical and financial goals. The Manager collaborates with medical staff, case management, revenue cycle, and IT to optimize care delivery and reimbursement.

Requirements

Bachelor’s degree in nursing or related field
Active RN license or LCSW required to practice in the state of Kentucky.
Case/Utilization Management (e.g., ACM, CCM, CMAC) certification.
Minimum seven years of UM/Case Management experience in an acute care of academic health system.
Minimum 4 years leadership experience.
Strategic thinking
Deep understanding of clinical workflows and regulatory requirements.
Strong communication and stakeholder engagement skills.
Data-driven decision-making and continuous improvement mindset.

Nice To Haves

Master’s degree preferred.

Responsibilities

Manage the day-to-day operations of the utilization review staff, including training, performance evaluation, and setting performance standards.
Create, implement, and maintain policies and procedures for the UM program, ensuring they align with regulations and organizational goals
Analyze UM metrics, identify trends, and prepare reports for senior management or quality improvement committees to guide decision-making and demonstrate the impact of the program.
Monitor the clinical review process to ensure patient care is appropriate, effective, and timely, and collaborate with physicians, case management and other professionals to improve utilization.
Identify opportunities to enhance the efficiency and accuracy of UM processes, often by working with physician advisors, case management, nursing leadership, and revenue cycle.
Ensure the department complies with all applicable state and federal guidelines and manage audits from regulatory agencies or health plans.
Provide mentorship, training and performance evaluations.
Ensure accurate documentation and data capture for billing and compliance.
Facilitate secondary reviews and appeals processes.
Performs other duties as assigned.
Participate in UM system-wide UM committees and initiatives.
Analyze utilization trends and recommend process improvements.
Coordinate certified training programs (e.g., InterQual, MCG).
Partner with IT to optimize UM-related systems (e.g., EMR, InterQual).