Supervisor, Utilization Management
About The Position
As a Supervisor of Utilization Management, you will lead a team of utilization review nurses by providing guidance, mentorship, and training to ensure timely, high-quality clinical reviews. Using your leadership and clinical expertise, you will collaborate with organizational leaders to refine utilization management policies, support adherence to evidence-based guidelines, and promote a culture of continuous improvement. In this role, you will conduct clinical reviews, ensure regulatory compliance, and facilitate communication with providers and payers. You will also monitor team performance, coach staff for professional growth, and identify opportunities for quality improvement and cost containment, while consistently upholding professional and ethical standards.
Requirements
- 5+ years of Utilization Management or Quality Improvement experience in managed care.
- 2+ years of clinical experience in an acute care or surgical hospital setting.
- Active RN license in the state of residence.
- Proficient in ICD-10, CPT, HCPCS, Revenue codes, and CMS/URAC guidelines.
- Familiar with evidence-based criteria such as MCG and health plan policies.
- Strong relationship-building skills with clear, effective communication.
- Able to thrive in a fast-paced, detail-oriented, deadline-driven environment.
Nice To Haves
- Health insurance experience
- Prior leadership experience
- MCG certification
- Compact State Nursing License
Responsibilities
- Supervise and support a team of Utilization Review Nurses, providing guidance, mentorship, and ongoing training.
- Collaborate with leadership to develop, implement, and maintain UM policies, procedures, and clinical guidelines.
- Monitor team performance against established productivity and quality goals, ensuring timely and accurate work.
- Deliver clear communication, coaching, and educational support to enhance team performance and compliance.
- Conduct clinical reviews to assess medical necessity and appropriateness of services, referring to Case Management or other programs as needed.
- Evaluate treatment plans and medical records to ensure alignment with evidence-based criteria and best practices.
- Ensure timely communication of utilization decisions with healthcare providers, payers, and clients.
- Collaborate with providers and internal teams to promote efficient resource use and identify opportunities for quality improvement and cost containment.
- Ensure compliance with regulatory requirements and accreditation standards including Medicare, Medicaid, and URAC.
- Maintain complete, accurate documentation of all UM activities and decisions.
- Stay current with industry regulations, standards, and emerging best practices in utilization management.
- Uphold strict confidentiality and demonstrate high standards of professional and ethical conduct.
- Perform other duties as assigned.
- Reasonable accommodation may be made to enable individuals with disabilities to perform essential duties.
Benefits
- Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
- Spending account options: HSA, FSA, and DCFSA
- 401K with company match and immediate vesting
- Flexible working environment
- Generous Paid Time Off to include vacation, sick leave, and paid holidays
- Employee Assistance Program that includes professional counseling, referrals, and additional services
- Paid maternity and paternity leave
- Pet insurance
- Employee discounts on phone plans, car rentals and computers
- Community giveback opportunities, including paid time off for philanthropic endeavors
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
