Manager Utilization Review & Clinical Doc Improvement

This position will manage activities and staff of the Utilization Review department. Supervise and evaluate the daily work of these teams in accordance with departmental and organizational policies. Provide education within the departments and the organization at large on clinical care, levels of care, and financial issues. Analyze and report data related to case management activities, payer activities, resource utilization, and clinical denials.

Lead hospital‑wide initiatives on behalf of the department. Monitor the performance, collection, and analysis of data to report on the effectiveness of process improvement to the organization and department. Participate in the planning, development, and implementation, and ongoing success of the Nurse Utilization Management Program. Educate members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members.

• Supervise and evaluate the daily work of teams in accordance with departmental and organizational policies.
• Provide direct supervision, coaching, and performance management of UM nursing staff.
• Foster a supportive, accountable, and collaborative team culture.
• Support recruitment, onboarding, training, and professional development of UM staff.
• Conduct regular staff meetings, performance evaluations, and competency assessments.
• Oversee daily utilization review activities, including admission reviews, continued stay reviews, and discharge planning support.
• Ensure appropriate documentation to support medical necessity and level‑of‑care determinations.
• Monitor workflow, productivity, and quality metrics to ensure timely and accurate reviews.
• Address escalations related to denials, delays, or complex utilization cases.
• Ensure compliance with CMS, state, Joint Commission, and payer‑specific requirements.
• Maintain knowledge of Inter Qual, MCG, or other approved utilization criteria.
• Participate in audits and regulatory surveys as needed.
• Support denial prevention strategies and appeal processes in collaboration with physician advisors and revenue cycle teams.
• Partner with physicians, physician advisors, case management, social work, finance, and revenue integrity teams.
• Serve as a subject matter expert for utilization management practices and regulations.
• Communicate effectively with payers and external partners when necessary.
• Analyze utilization data, trends, and outcomes to identify opportunities for improvement.
• Participate in performance improvement initiatives and system optimization.
• Support reporting related to length of stay, denials, avoidable days, and payer performance.
• Function as a resource to staff and resolve issues that arise internally and with payors.
• Mentor staff and support learning opportunities to foster success.
• Work directly with payors and Managed Care to enhance communication and improve authorization processes.
• Assist with the management of denials and high‑risk cases.
• Establish and maintain effective internal and external relationships to achieve departmental and organizational goals.
• Provide information to Case Managers on organizational initiatives and professional trends in practice.
• Represent CRM on organizational committees.
• Ensure Case Management activities are in regulatory compliance (JC, CMS).
• Track clinical, functional, operational, quality and financial data related to CRM.
• Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.
• Implement processes to continually improve performance, reduce denials, and optimize reimbursement.
• Update departmental procedures to reflect changes in payor contracts and departmental processes.

• Strong leadership, communication, and interpersonal skills.
• Analytical and problem‑solving abilities.
• Ability to manage multiple priorities in a fast‑paced environment.
• Knowledge of healthcare regulations, reimbursement, and utilization review standards.
• Commitment to patient‑centered care and organizational values.

Master's Degree (Required)

7 years Healthcare…