The Manager, Utilization Review-RN oversees hospital utilization review functions. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective care and appropriate case status based on evidence-based criteria. This position oversees department alignment with payer policy and revenue cycle processes. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care.

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The Manager, Utilization Review-RN oversees hospital utilization review functions. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective care and appropriate case status based on evidence-based criteria. This position oversees department alignment with payer policy and revenue cycle processes. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care.

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EDUCATION: Graduate of accredited school of nursing or other healthcare professional field. Master’s degree in a health-related field, health care management or business management strongly preferred with a minimum of 3 years case management/utilization review experience or a Bachelor of Science in Nursing (BSN) with a minimum of 5 years case management/utilization review experience required.

YEARS OF EXPERIENCE: 3+ years of leadership or supervisory experience preferred, Lean/Six Sigma or process improvement experience preferred.

REQUIRED SKILLS AND KNOWLEDGE:

• Strong knowledge of payer systems, Medicare/Medicaid, and regulatory requirements.
• Participation in professional organizations and ongoing professional development relating to utilization review.
• Experience with EHR systems and utilization review software.
• Leadership and team development
• Clinical and regulatory expertise
• Financial and utilization management
• Critical thinking and problem-solving
• Communication (oral and written) and conflict resolution
• Data analysis and performance improvement
• Technology/systems proficiency
• Time management and multi-tasking.

LICENSES REGISTRATIONS &/or CERTIFICATIONS: Active OH RN License required; Certified Case Manager (CCM)/Accredited Case Manager (ACM) preferred

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Leadership & Team Management

• Supervise and support Utilization Review Nurses and administrative support staff.
• Develop and maintain job descriptions and policies and procedures to be compliant with accrediting and regulatory agencies.
• Provide coaching, performance evaluations, and staff development.
• Develop, maintain and oversee orientation plans for new staff, conducting new hire reviews according to Human Resource policies.
• Develop staffing plans, schedules, and productivity benchmarks to ensure clinical competency and patient coverage.
• Foster a collaborative, patient-centered team environment
• Create and implement action plans based upon employee satisfaction surveys and other feedback.
• Provide interdepartmental training and support on case management and utilization review requirements, tools, and processes.
• Participate in development, implementation and oversight of budget
• Represent department by presenting information in committees and workgroups.

Utilization Review Oversight

• Ensure accurate application of evidence-based criteria such as InterQual and Milliman Care Guidelines.
• Ensure timely clinical reviews and follow-up for payer approvals.
• Collaborate with Physician Advisor (PA) to ensure criteria are applied appropriately for correct patient status.
• Monitor admission status, length of stay (LOS), and medical necessity.
• Oversee payer communications and processes, including authorizations, concurrent reviews, and denial management.
• Remain current on individual payer policies.
• Collaborate with Revenue Cycle partners to analyze trends and implement strategies to reduce denials.

Regulatory Compliance & Quality

• Ensure compliance with Medicare Conditions of Participation and other federal/state requirements.
• Maintain readiness for audits (e.g., CMS, Joint Commission).
• Develop and enforce policies, procedures, and documentation standards.
• Lead quality improvement initiatives focused on denial reductions and appropriate case status
• Support processes to achieve optimal clinical and financial outcomes.
• Provide input and oversight of platforms/systems for effective documentation and data tracking.

Care Coordination & Collaboration

• Collaborate with physicians, nursing leadership, finance, and ancillary departments to facilitate patient access to the most appropriate level of care across the continuum and to continuously improve quality of care.
• Participate in interdisciplinary rounds as needed and escalation processes.
• Serve as a liaison between department and external payers or agencies.

Data Analysis & Reporting

• Collaborate with IT and data analytics partners to coordinate collection, analysis and reporting of outcomes data reflecting the effectiveness of the UR department.
• Track and report key performance indicators (KPIs), including:
  • Denial rates and peer to peer outcomes
  • Appropriate status and observation to inpatient conversions
  • Discharge delays
• Use data to drive operational improvements and strategic planning.

Performs other duties as assigned to support the work of the department and health system.