Manager, Utilization Management

The Utilization Management Manager (UMM) proactively conducts clinical reviews according to industry accepted clinical criteria guidelines. The UMM serves as interdepartmental liaison identifying level of care and opportunities for improvement from both internal and external sources including regulatory agencies.

Responsibilities

• Conduct clinical reviews in accordance with contractual, regulatory, and organizational requirements.

• Collaborate with the Physician Advisor on clinical review discussions as appropriate.

• Serve as a liaison between the Care Management Department and attending physicians.

• Communicate changes in patient level of care to the Care Manager based on physician orders and updated clinical information.

• Provide guidance to Care Management staff on regulatory, utilization management, and managed care requirements.

• Monitor compliance with departmental performance standards.

• Participate in departmental meetings, committees, and interdisciplinary initiatives as assigned.

• Identify regulatory, managed care, and compliance issues contributing to denials and report findings to department leadership.

• Support administrative staff by providing information, guidance, and operational assistance.

• Facilitate effective communication across departments to ensure continuity of care and collaboration.

• Maintain strict patient confidentiality and protect electronic health information in compliance with hospital policies, HIPAA, New York State regulations, and Peer Review Organization (PRO) requirements.

• Graduate of an accredited School of Nursing with a current New York State Registered Nurse (RN) license required.

• BSN or Bachelor’s degree in a healthcare-related field preferred.

• Minimum of five (5) years of recent clinical experience in medical-surgical nursing or a relevant specialty area.

• Previous Utilization Management and/or Care Management experience in an acute care hospital or managed care setting required.

• Commitment to ongoing professional development through continuing education and certification related to Utilization and Care Management.

• Proficiency with Microsoft Office applications, including Word and Excel; experience with EPIC, Midas, STAR, and other hospital information systems preferred.

• Ability to obtain specialty-specific clinical consultation when needed to support utilization reviews and appeals.

• Strong understanding of reimbursement methodologies, utilization management principles, and financial implications of clinical decisions.

• Knowledge of evidence-based clinical guidelines and medical necessity criteria.

• Familiarity with federal, state, Peer Review Organization (PRO), and managed care regulations preferred.

• Working knowledge of payer requirements, medical necessity guidelines, levels of care, continuity of benefits, and utilization review processes.

• Understanding of current healthcare trends, managed care principles, patient care best practices, and performance improvement methodologies.

St. Catherine of Siena Hospital is a proud member of Catholic Health and has served the residents of the Smithtown area for more than 50 years. St. Catherine’s is located on the north shore of Long Island in Smithtown. The campus is comprised of 296-bed not-for-profit community hospital; a 240-bed nursing and rehabilitation care center; and a 60,000 square foot medical office building. Our nurses, physicians, and support staff are devoted to providing advance health care in an environment of compassion to our patients, their families, and our community. Our Mission is to create an environment of healing and compassion, to offer care to those in need and to provide a spirit of mutual respect while upholding our religious mission.

St. Catherine of Siena Hospital is dedicated to providing a supportive environment, committed to the highest standards of patient care, where health care professionals can develop their expertise and strengthen their credentials. Our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence based practice to improve outcomes - to every patient, every time., At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, employees are eligible for generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.