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 = $

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.

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.

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.

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 organizational efforts to optimize reimbursement while maintaining regulatory compliance and quality patient care.

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.…