Manager Of Utilization Review

The Utilization Management (UM) RN Manager is responsible for the day-to-day leadership, operational oversight, and performance management of the Utilization Management nursing team. Reporting to the UM RN Director, the Manager translates department strategy, regulatory and payer requirements, approved clinical review criteria, and organizational priorities into consistent daily execution.

The role provides direct supervision, coaching, workflow management, clinical-operational support, and performance oversight for assigned UM staff. The Manager collaborates with physician advisors/medical directors, case management, clinical operations, revenue cycle, payer relations, quality, compliance, and other stakeholders to support timely, accurate, evidence-informed utilization management decisions and appropriate stewardship of healthcare resources.

Bachelor of Science in Nursing (BSN) required, or equivalent qualification consistent with organizational policy.

Master’s degree in Nursing, Healthcare Administration, Business Administration, Public Health, or a related field preferred.

Five or more years of progressive clinical nursing and/or utilization management experience preferred, including three or more years of experience in utilization management, utilization review, case management, managed care, or a closely related function.

Prior formal leadership experience required; two or more years of supervisory or management experience preferred.

Current Ohio State Board of Nursing license required.

Knowledge of utilization management and utilization review principles, including prospective, concurrent, and retrospective review.

Knowledge of medical necessity, patient status, level-of-care review, authorization processes, payer requirements, denial prevention, and escalation pathways.

Knowledge of evidence-based clinical review criteria and appropriate use of clinical decision-support tools.

Knowledge of regulatory and accreditation requirements affecting utilization management and clinical review.

Demonstrated ability in people leadership, coaching, performance management, conflict resolution, and change management.

Demonstrated ability to interpret operational analytics and KPIs, conduct root-cause analysis, and drive process improvement.

Demonstrated ability to communicate effectively across interdisciplinary teams, including nursing, physicians, physician advisors, payers, revenue cycle, and leadership.

Demonstrated application of professional nursing judgment, ethical practice, confidentiality, and appropriate stewardship of healthcare resources.