Manager, Utilization Management

Provide operational oversight for utilization review and hospital authorizations. Manage staff performance, discipline, evaluation and termination. Utilize clinical assessment knowledge and critical thinking skills to lead the team and enhance outcomes. Champion implementation of practice changes and serve as a supportive change agent. Collaborate with various departments to address authorization and medical necessity concerns. Contribute to policy formulation and decision-making using knowledge of Utilization Management standards and government and contractual guidelines. Build relationships to promote interdisciplinary collaboration. Evaluate the efficiency, clinical appropriateness, and necessity of medical services and procedures in the most resourceful clinical setting. Other duties as assigned.Knowledge, Skills, and Abilities

• Current knowledge of utilization/denial management key accountabilities to engage in development and implementation of education and training of key initiatives. [Required]
• Capacity and desire to lead others; ability to manage fast-paced, multi-faceted environment and maintain service standards. [Required]
• Provide education and detailed instructions regarding workflows and strategic initiatives to varied groups of adult learners in various settings. [Required]
• Expertise in medical necessity screening determinations and status recommendations. [Required]
• Expertise in EMR systems, primarily in utilization review/denial management and roles and responsibilities of various disciplines. [Required]
• Ability to navigate and utilize other related software and databases for educating new system end-users. [Required]
• Demonstrates strong analytical, problem solves skills and the ability to analyze complex data. [Required]
• Proficiency in use of spreadsheets and report software. [Required]
• Proficient in using multiple computer applications interchangeably. [Required]
• Communicates professionally with an acceptable use of English (speaking, reading, and writing). [Required]
• Knowledge of payer guidelines, reimbursement methodologies, and appeals processes and their impact. [Preferred]
• Ability to execute Excel spreadsheets and Power Point presentations. [Preferred]
• Ability to present information in written and presentation form to various Executive Leaders. [Preferred]
• Overall understanding of payer contracts and government/regulatory compliance. [Preferred]
• Working knowledge of RAC (Recovery Audit Contractor) Manager Program (RM). [Preferred]

Education:

• Associate’s of Nursing [Required]
• Bachelor’s of Nursing [Preferred], * 2+ utilization management or case management [Required]
• 3+ clinical nursing experience [Required]
• 5+ clinical nursing in an acute care setting [Preferred]
• Experience working in electronic health records [Preferred]
• Precepting, People Leader, or Informal Leader (i.e., charge nurse, team lead, etc.) [Required]
• Supervisor in a Utilization Management or Case Management department [Preferred], * Registered Nurse (RN) [Required] AND
• Accredited Case Manager (ACM) [Preferred] OR
• Certified Case Manager (CCM) [Preferred]

Pulled from the full job description

• 403(b)
• Paid parental leave
• Parental leave
• Health insurance
• Paid time off
• Vision insurance
• Dental insurance, * Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.