Utilization Review RN Manager

Work Status Details: REGULAR FULL TIME | 80.00 Hours Every Two Weeks

Shift: Days
Pay Rate Type:
Annual Salary

Location:

Yuma Medical Center

Listed is the base hiring salary range offered for this position. Actual salaries may vary depending on factors, including but not limited to skills and experience. The salary range listed is just one component of the total rewards/compensation package offered to candidates.
Min = $
Mid = $
Max = $

Summary:

Under the supervision of the Director of Care Management, UR RN Manager is responsible for the operational leadership, oversight, and performance of the hospital's Utilization Review program. This position ensures compliance with federal and state regulations, accreditation standards, payer requirements, and organizational policies related to medical necessity, level of care determination, admission status, prior authorization, and denial prevention. The UR RN Manager provides leadership to Utilization Review and Denials Nurses to ensure appropriate patient status, timely medical necessity reviews, effective physician communication, and accurate reimbursement while supporting high-quality patient care.

The manager develops staff, monitors key performance indicators, and leads performance improvement initiatives, and collaborates with Revenue Cycle, Clinical Documentation Integrity (CDI), Quality, Compliance, and physician leadership.

Leadership and Department Operations: Provides leadership, oversight, and daily operational management for the Utilization Management Department. Supervises, coaches, mentors, and evaluates Utilization Review Nurses and Denials Management staff to promote professional growth and high performance. Ensures appropriate staffing levels, workload distribution, and productivity standards to meet departmental and organizational goals. Establishes performance expectations and accountability measures that support quality, efficiency, and regulatory compliance.

Promotes a culture of collaboration, service excellence, employee engagement, and continuous improvement. Participates in departmental budget planning, resource allocation, and operational decision-making.

Supports recruitment, onboarding, orientation, and ongoing competency validation of department staff.

Utilization Management Program Oversight: Provides oversight of admission status determinations, medical necessity reviews, observation services, continued stay reviews, and denial management activities. Ensures timely and accurate utilization review processes that support appropriate patient status assignment and reimbursement. Oversees escalation processes for complex utilization management cases and payer disputes. Collaborates with Physician Advisors, medical staff, Case Management, and Revenue Integrity teams to ensure appropriate level-of-care determinations.

Monitors trends related to observation utilization, inpatient status conversions, authorization requirements, avoidable delays, and denials. Develops and implements strategies to reduce preventable denials and improve reimbursement outcomes.

Regulatory and Accreditation Compliance: Ensures departmental compliance with all applicable federal, state, and accreditation standards governing utilization management activities. Maintains knowledge of CMS Conditions of Participation, Medicare regulations, Medicaid requirements, payer-specific guidelines, and hospital-issued notices. Oversees processes related to patient status notifications, beneficiary notices, and documentation requirements. Ensures utilization management practices align with organizational policies and regulatory expectations. Serves as a resource to leadership and staff regarding regulatory changes and compliance requirements.

Coordinates audits, monitoring activities, and corrective action plans when compliance concerns are identified.

Physician and Interdisciplinary

Collaboration:

Serves as a subject matter expert and resource for physicians, advanced practice providers, case managers, revenue cycle staff, and organizational leadership. Collaborates with Physician Advisors and medical staff to support appropriate documentation, status determinations, and medical necessity compliance. Facilitates effective communication between clinical departments, payers, utilization review staff, and executive leadership. Supports physician education initiatives related to regulatory requirements, admission status, documentation, and utilization management best practices.

Denials Prevention and Revenue Integrity: Oversees denial prevention, denial management, appeal processes, and recovery efforts. Identifies trends affecting reimbursement and develops action plans to improve financial performance. Collaborates with Revenue Cycle, Patient Financial Services, and Contracting departments to resolve reimbursement issues and address payer concerns. Reviews denial data and appeal outcomes to identify opportunities for education, process improvement, and risk mitigation.

Supports…