Manager, Utilization Review (RN)

Children's Healthcare of Atlanta • GA

140d

About The Position

Provides leadership and oversight of the Utilization Review department, ensuring appropriate utilization of healthcare resources. Effectively manages all utilization review functions, including clinical reviews, concurrent authorization and denials management, status changes, and identification and escalation of payer trends. Partners with a broad range of stakeholders, including case management, social work, patient access, clinical operations, physicians, managed care, and IS&T. Establishes and manages productivity, quality, and other key performance indicators, providing feedback to staff related to performance regularly. Produces reporting and performs analysis of data relevant to utilization review functions.

Requirements

• 5 years of RN experience in emergency, intensive care, and/or medical-surgical acute care settings
• 2 years of experience in a supervisory or management role
• Bachelor of Science in Nursing
• Licensure as a Registered Nurse in the single State of Georgia or multi-state through the Enhanced Nurse Licensure Compact

Nice To Haves

• Master's degree in nursing, business, or other healthcare related field
• Utilization review experience
• Pediatric experience preferred

Responsibilities

• Oversees management and operations of the Utilization Review department, including developing, directing, and managing all members of the team.
• Functions as a subject matter expert for staff and other stakeholders, demonstrating a thorough knowledge of all utilization review processes, policies and procedures.
• Develops, maintains, and communicates utilization review policies and procedures and ensures compliance with organizational, state and federal regulations.
• Recruits, hires, orients, and continuously trains new employees to ensure success and a thorough understanding of necessary policies, processes, and procedures.
• Develops staff and departmental performance expectations, metrics, and goals and holds self and staff accountable.
• Establishes and communicates performance and behavioral standards and follows appropriate disciplinary courses of action when counseling staff.
• Uses data to monitor and analyze performance against standards and goals, identify trends, and make adjustments as necessary.
• Collaborates with a broad range of stakeholders, including case management, social work, patient access, clinical operations, physicians, managed care, and IS&T.
• Communicates with and educates physicians and other clinical staff as needed regarding utilization review policies, practices, and procedures.
• Mentors team members to encourage personal and professional growth.
• Encourages ongoing skill development by providing opportunities for continued education.
• Performs other duties as necessary or assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees