Utilization Review and Clinical Program Manager

Lakewood Health System • Staples, MN

3d

About The Position

The Utilization Review and Clinical Programs Manager oversees utilization review activities to support medical necessity, appropriate patient status, denial prevention, and effective use of healthcare resources. The position also leads and coordinates Lakewood Health System’s trauma and stroke programs, ensuring regulatory compliance and readiness for program designation. The manager works with Nursing Administration, medical directors, providers, nursing, care management, and interdisciplinary departments to strengthen clinical processes, improve quality outcomes, support regulatory compliance, and promote patient-centered care.

This role conducts medical necessity reviews using MCG criteria; monitors patient status and length of stay; identifies documentation opportunities; and supports payer reviews, denial prevention, and appeals. As the designated Trauma Program Manager and Stroke Coordinator, the role oversees program compliance, performance improvement initiatives, required reporting, education, and designation readiness.

Requirements

• Current, unrestricted Minnesota Registered Nurse (RN) license.
• Acute care nursing experience, including emergency and trauma care.
• Strong clinical judgment, organizational skills, and attention to detail.
• Excellent communication, documentation review, and interdisciplinary collaboration skills.
• Ability to analyze clinical data and identify opportunities for improvement.
• Ability to maintain required role-specific competencies.

Nice To Haves

• Experience in utilization review, trauma program management, stroke coordination, care management, or quality improvement.
• Familiarity with MCG criteria, Medicare and Critical Access Hospital requirements, and Minnesota Department of Health trauma and stroke designation standards.

Responsibilities

• Conduct medical necessity reviews using MCG criteria.
• Monitor patient status and length of stay.
• Identify documentation opportunities and support payer reviews, denial prevention, and appeals.
• Serve as the designated Trauma Program Manager and Stroke Coordinator.
• Oversee trauma and stroke program compliance, performance improvement initiatives, required reporting, education, and designation readiness.
• Collaborate with medical directors, providers, nursing, care management, and other departments to improve clinical processes and support regulatory compliance.
• Promote effective resource utilization and contribute to improved quality outcomes and patient-centered care.
• Maintain required role-specific competencies.

Benefits

• Generous planned time off and wellness time off.
• 401(k) match.
• Annual tuition assistance of $2,000 per year.
• Employer HSA contributions.
• Employer-paid premiums for individual-only healthcare coverage.
• Opportunities for growth within the system and support in pursuing personal goals.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed