Registered Nurse (RN) Manager

ProviDRs Care•Wichita, KS

56d•Onsite

About The Position

The RN Manager of Integrated Health Management manages the daily clinical and administrative operations of Utilization Review, Case Management, and Care Navigation for a third-party administrator serving self-funded health plans. Reporting directly to the Director, the Manager translates departmental priorities and approved policies into effective workflows, supervises department personnel, monitors performance, resolves operational issues, and ensures timely, consistent service to members, employer groups, providers, brokers, vendors, and internal partners. The Manager also maintains an active clinical role by completing utilization reviews as workload and departmental needs require. The position exercises independent judgment within established policies, plan documents, regulatory requirements, clinical criteria, and delegated authority. Policy creation and approval remain under the Director and other designated organizational authorities.

Requirements

Active, unrestricted Registered Nurse license in Kansas.
Bachelor of Science in Nursing from an accredited nursing program.
At least five years of clinical nursing experience, preferably in medical-surgical nursing or a related setting that provides broad clinical knowledge.
At least three years of healthcare management, supervision, or formal leadership experience.
Demonstrated ability to supervise clinical and nonclinical staff, manage competing priorities, and address urgent or sensitive matters.
Working knowledge of clinical documentation, medical terminology, levels of care, treatment settings, and interdisciplinary care coordination.
Strong clinical judgment and the ability to recognize urgent, complex, high-risk, and high-cost situations.
Ability to interpret plan documents, clinical criteria, procedures, service standards, contracts, and regulatory requirements.
Clear written and verbal communication with members, staff, providers, employer groups, vendors, and senior leaders.
Sound judgment when handling confidential information, personnel matters, competing priorities, and escalated concerns.
Ability to analyze operational and clinical data, identify trends, and use performance results to improve workflows and staff performance.
Proficiency with standard office applications and the ability to learn claims, care-management, utilization-review, customer-service, and reporting systems.

Nice To Haves

Experience in utilization review, case management, care management, discharge planning, managed care, health-plan operations, or a third- party administrator environment.
Knowledge of self-funded health plans, ERISA plan administration, stop-loss reporting, prior authorization, appeals, provider networks, and pharmacy-benefit coordination.
Professional certification related to case management, utilization management, quality, or managed care.

Responsibilities

Direct daily operations across Utilization Review, Case Management, and Care Navigation and coordinate priorities among the three functions.
Assign and redistribute work based on volume, urgency, staff availability, service requirements, and clinical risk.
Establish daily and weekly priorities, monitor completion, and address backlogs, delays, documentation gaps, and coverage needs.
Provide performance coaching, feedback, education, and corrective action in accordance with organizational policy and in coordination with Human Resources and the Director when required.
Participate in hiring, onboarding, competency assessment, training, performance evaluation, staff development, and retention efforts.
Develop the Supervisor’s leadership skills and clarify responsibilities delegated to the Supervisor.
Promote consistent communication and collaboration among clinical staff, operational teams, and organizational leadership.
Perform prospective, concurrent, and retrospective utilization review using applicable plan benefits, clinical criteria, regulatory requirements, and internal procedures.
Consult on complex, high-risk, high-cost, or clinically sensitive case-management matters and assist staff with barriers that require advanced nursing judgment.
Ensure timely identification, assessment, outreach, care planning, documentation, follow-up, and closure of case-management opportunities.
Support care-navigation activities involving provider access, steerage, member education, appointment coordination, ancillary services, and escalation to licensed clinical staff.
Coordinate physician review, peer-to-peer activity, adverse determinations, appeals, transition-of-care needs, and urgent clinical escalations as applicable.
Maintain appropriate clinical boundaries and ensure that benefit determinations and clinical decisions are made by individuals with the required authority and credentials.
Develop, implement, and revise operational workflows, forms, job aids, documentation standards, and staff instructions within approved policy.
Identify process gaps and recommend policy changes to the Director; do not independently establish or approve departmental policy.
Ensure consistent use of departmental systems, reports, clinical criteria, communication tools, and documentation platforms.
Coordinate workload coverage for absences, urgent requests, high-volume periods, system interruptions, and after-hours escalations.
Lead operational projects assigned by the Director and communicate implementation needs, risks, and results.
Monitor departmental service standards, turnaround times, productivity, documentation timeliness, caseloads, outcomes, and key performance indicators.
Conduct or oversee chart audits, quality reviews, competency validation, corrective-action follow-up, and trend analysis.
Support compliance with applicable federal and state requirements, ERISA plan requirements, utilization-review standards, privacy requirements, contracts, plan documents, and internal policies.
Escalate suspected compliance concerns, privacy or security incidents, critical quality findings, untimely determinations, and other material risks to the Director promptly.
Prepare accurate reports and summaries for the Director, executive leadership, committees, employer groups, brokers, stop-loss partners, and other approved recipients.
Support utilization-review committee activities, annual program evaluation, criteria governance, delegated-vendor oversight, and corrective- action monitoring as assigned.
Resolve routine and escalated service issues involving vendors, employer groups, providers, brokers, pharmacy partners, networks, and internal departments within delegated authority.
Coordinate complex cases and high-cost matters with stop-loss partners and other authorized stakeholders while protecting confidential information.
Clarify operational requirements, follow up on outstanding items, and elevate contractual, policy, financial, reputational, or unresolved issues to the Director.
Represent Integrated Health Management in internal and external meetings as assigned and communicate decisions and action items to affected staff.