Nurse Manager - Utilization Management

Job Overview

When you join the growing BILH team, you’re not just taking a job, you’re making a difference in people’s lives. The Utilization Management (UM) Manager leads the UM team to maintain effective and efficient processes for determining appropriate patient admission status, ensuring compliance with regulatory and reimbursement requirements of commercial and government payers. This role collaborates with multiple revenue‑cycle functions and other clinical teams.

• Ensures that Utilization Review nurses consistently recommend appropriate admission status and provides education as needed.
• Interacts with physicians to manage high‑risk patients most likely to benefit from Utilization Review intervention.
• Serves as a resource for the utilization review staff and other stakeholders to ensure consistent and accurate patient status determinations for appropriate claim submission.
• Collaborates with multidisciplinary team members to ensure all patients are reviewed and the correct admission status is applied.
• Manages performance of UM staff, coaching staff, administering corrective action, conducting performance evaluations, and overseeing audits.
• Conducts new employee interviews, selects hires, and designs orientation, training, and competency development programs.
• Assigns and reviews staff schedules and workflows; works closely with other administrative and clinical areas under the direction of the Executive Director and VP of Revenue Cycle/Chief Revenue Officer.
• Maintains documented, up‑to‑date policies and procedures; ensures key processes have valid outcome measures that are monitored for compliance and reported to stakeholders.
• Performs concurrent and retrospective UM activities; tracks, evaluates, and reports data.
• Monitors effectiveness/outcomes of the UM program, identifies metrics, evaluates data, reports results, and designs and implements process improvement projects.
• Leads or participates in process improvement initiatives, working with various departments and multidisciplinary staff.
• Assists the Executive Director in evaluating systems and processes in collaboration with revenue cycle and clinical areas.
• Assists leadership in managing vendor relationships, IT set‑up, reports, data analysis, compliance reviews.
• Monitors regulatory requirements for Utilization Management.
• Attends mandatory education programs required by the organization and maintains continuing education records for licensing, certification and enhancement.

Maintains strict adherence to the LHMC and BILH Confidentiality Policy and other LHMC policies, incorporates guiding principles, mission statement and goals into daily activities, complies with behavioral expectations, demonstrates commitment toward meeting and exceeding customer service standards, participates in quality improvement activities and completes mandatory education.

• Bachelor’s Degree required;
  Master’s Degree preferred.
• Current license as a Registered Nurse.
• Current and accurate knowledge of commercial and government payers, and Joint Commission regulations and guidelines related to Utilization Review.
• Well‑developed knowledge and skills in medical necessity and patient status determination.
• Effective verbal communication, problem‑solving, conflict resolution skills.
• Basic knowledge of quality improvement techniques.
• Demonstrated ability to organize and work independently; communicate effectively with medical and hospital staff.
• Proven knowledge of Revenue Cycle functions.
• Minimum 3 years of medical/surgical nursing care experience, including a leadership role.
• Two years of case management or utilization management experience desirable.
• Vaccination against influenza (flu) is required as a condition of employment.

• Executive Director, HIM, Coding & UR:
  Receives direction regarding priorities, assignments, coordination and outcomes.
• Clinical Leaders:
  Receives direction and training from Case Managers.
• Collaborates on complicated or high‑risk patients admitted to the Clinic.
• Attending Physicians:
  Coordinates appropriate documentation.
• Medical Director for Managed Care, Physician Advisors:
  Works collaboratively managing the process of Utilization Review throughout the system.

$USD – $USD (annual base salary range).

Equal Opportunity Employer/Veterans/Disabled.