Manager, Utilization Management (RN)

Sutter Health•Sacramento, CA

21h

About The Position

The Manager, RN – Utilization Management is a clinical and operational leader responsible for overseeing a multidisciplinary team of registered nurses and non-clinical staff supporting utilization management functions across risk-based populations, including HMO, Medicare Advantage (MA), and Medicare FFS. This role provides day-to-day leadership for utilization management operations with a strong emphasis on In-Network Utilization, concurrent review, post-acute (SNF) utilization management, and Medicare FFS performance. The Manager plays a critical role in driving cost containment, appropriate utilization, and revenue optimization through proactive clinical interventions, data-driven decision-making, and effective use of technology. This position partners closely with hospital case management, physicians, medical directors, post-acute providers, health plan partners, and system stakeholders to ensure care is delivered at the right level, in the right setting, at the right time, while meeting regulatory and contractual requirements.

Requirements

Bachelor's: BS in Nursing or Health Administration OR Master's: Masters of Social Work for Social Work Candidates Only OR Master's: MS in Nursing, Case management, or related field
RN-Registered Nurse of California OR LCSW-Licensed Clinical Social Worker
8 years recent relevant experience in Utilization / Case Management role
Knowledge of Accreditation Council for Medical Affairs (ACMA), Case Management Society of America (CMSA) and National Association of Social Workers (NASW) Standards of Practice
Knowledge of available health care and community resources
A broad knowledge base of health care delivery and case management within a managed care environment.
Comprehensive knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: Centers for Medicare and Medicare Services (GR) Grouper (CMS), Title 22, CHA Consent Manual, CDPH and The Joint Commission (TJC).
Verbal and written communication skills.
Group presentation design and facilitation skills.
Demonstrated ability to develop and manage complex projects.
Working knowledge of InterQual criteria.
Working knowledge of MIDAS and experience with an E.H.R. (EPIC preferred)
Ability to promote teamwork and to effectively function in teams, both as a leader and as a team member.
Ability to interact effectively with key internal and external constituents using collaboration, negotiation and analytical problem resolution skills.
Effective human relations and interpersonal skills necessary to lead the efforts of diverse health professionals to meet program objectives.
Ability to work effectively in a fast paced environment, directing services at multiple locations.
Analytical and mathematical skills.
Demonstrated ability to implement continuous quality improvement processes and techniques, including benchmarking and outcomes measurements.
PC skills, word processing, spreadsheets and managed care software programs.
Adheres to Sutter health policies and procedures and supports Sutter health philosophies and initiatives.
Participates as member of the utilization Management committee (UMC).