Mgr Utilization Review

Beacon Health System • Granger, IN

70d

About The Position

The Manager of Utilization Review is responsible for overseeing the utilization review process to ensure the appropriate, efficient, and cost-effective use of healthcare resources. This role supports clinical and financial outcomes by coordinating with medical staff, case managers, and payors, and by implementing strategies that align with Beacon Health System's mission and regulatory requirements.

Requirements

• Bachelor's Degree in Nursing required; Master's in Nursing, Healthcare Administration, or related field preferred.
• Current RN license in the state of Indiana.
• Minimum 3-5 years of experience in utilization review or case management.
• Prior supervisory or management experience strongly preferred.

Nice To Haves

• Strong analytical and critical-thinking skills.
• Excellent communication and interpersonal abilities.
• Proficiency in healthcare software and electronic health records.
• Knowledge of reimbursement methodologies.
• Ability to lead change and foster a culture of continuous improvement.

Responsibilities

• Lead and mentor a team of Utilization Review Nurses.
• Develop and implement utilization management protocols and strategies.
• Ensure compliance with Medicare, Medicaid, and third-party payor requirements.
• Collaborate with the Director of Case Management to align departmental goals.
• Monitor medical necessity of admissions, duration of stays, and services rendered.
• Address authorization challenges and reduce preventable denials.
• Maintain accurate documentation of all Utilization Review activities.
• Analyze utilization data to identify inefficiencies and opportunities for cost savings.
• Implement LEAN methodologies to improve Utilization Review processes.
• Prepare reports for oversight committees and leadership.
• Assess learning needs and develop orientation and continuing education programs.
• Validate staff competencies through audits and direct observation.
• Serve as a resource for complex Utilization Review decision-making.
• Ensure adherence to medical necessity criteria - Xsolis, MCG, and InterQual guidelines.
• Support quality improvement initiatives in collaboration with the Quality team.
• Maintain up-to-date knowledge of healthcare regulations and technologies.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees