Posting Title RN Manager, Utilization Review

Job Description

Be a part of a world‑class academic healthcare system, Company, as a RN Manager in the Rev Cycle Department. This position will be primarily a work from home opportunity with the requirement to come onsite as needed. You may be based outside of the greater Chicagoland area.

The Manager of Utilization Review (UR) provides leadership and oversight of utilization review activities across the health system, including the academic medical center and affiliated community hospitals. This position ensures consistent application of medical necessity criteria, compliance with payer and regulatory requirements, and alignment of utilization management (UM) practices across all entities. The Manager serves as the primary liaison between the health system, external utilization review vendors, and internal stakeholders including physicians, case management, and revenue cycle teams.

The role focuses on optimizing patient status determinations, reducing avoidable denials, and supporting appropriate reimbursement through collaboration, education, and data‑driven oversight.

Essential Job Functions

• Oversee daily utilization review operations across multiple hospital sites to ensure timely, compliant reviews and consistent application of UM standards.
• Develop, implement, and monitor system‑wide UR policies, workflows, and performance metrics.
• Identify opportunities and maintain responsibility for technology optimization, including EMR workflows and other UR platforms.
• Supervise and mentor UR staff and coordinate work between onsite and centralized review teams as applicable.
• Serve as a subject matter expert on medical necessity, payer requirements, and regulatory standards (CMS, Joint Commission, state). Maintain oversight of interdisciplinary education to ensure consistent understanding of UM criteria across departments (case management, physician advisors, financial counselors, etc.).
• Act as the primary point of contact for the system’s external Utilization Review vendor, ensuring high‑quality, timely reviews and compliance with contractual performance metrics.
• Monitor vendor performance dashboards, review audit findings, and lead performance improvement initiatives. Provide input to contract negotiations.
• Collaborate with external partners to streamline communication, resolve escalations, and enhance consistency across hospital sites.
• Track and analyze utilization metrics, denial trends, and audit outcomes across the system.
• Prepare regular reports for leadership highlighting performance, compliance, and financial impact. Benchmark against national standards and peer institutions, and create action plans to meet those standards.
• Identify opportunities for improvement in review processes, technology use, and documentation practices.
• Provide root cause analysis of denials, and missed reviews as applicable.
• Participate in and/or coordinate daily multidisciplinary rounds with clinical and case management teams to support real‑time status determinations and discharge planning.
• Serve as a liaison between hospitalists, attending physicians, physician advisors, CDI, and UR staff to ensure appropriate documentation of medical necessity and level of care.
• Build strong working relationships with Revenue Cycle, Case Management, CDI, and Physician Leadership teams to ensure alignment of clinical and financial objectives.
• Partner with Denials, CDI, Payer compliance, and Revenue Integrity teams to address payer trends and support denial prevention strategies.
• Provide education and support to clinical staff and physicians on UM criteria (Inter Qual, MCG), medical necessity documentation, and payer requirements.
• Stay current with regulatory updates, payer policies, and value‑based care trends impacting utilization management.
• Participate in policy and training development for payer trends applicable to the UR function.
• Ensure all UR activities comply with CMS Conditions of Participation and other regulatory standards, and monitor competency assessments of UR staff.

Required Qualifications

• Minimum 5 years of clinical experience in an acute care setting.
• Minimum 3–5 years of experience in Utilization Review, Case Management, or…