Manager, Utilization Review

Health Business Solutions LLC; Manila; On-site; PHP 900,000 - 1,500,000; Full time

Job summary

Health Business Solutions LLC is seeking a Manager, Utilization Review to oversee daily operations of Utilization Review and lead a team of Utilization Review Nurses. The role focuses on care coordination, cost management, and maintaining high patient care standards.

You will supervise and mentor the UR nursing team, develop individualized care plans, monitor utilization, and drive quality improvement while ensuring regulatory compliance.

Qualifications

• Current RN license; PHRN/USRN preferred.
• BSN required; MSN preferred.
• Minimum 2 years leadership in case management or care coordination.
• Strong clinical assessment and critical thinking.
• Excellent communication and interpersonal skills.
• Knowledge of healthcare regulations, insurance processes, and quality improvement.
• Proficiency with EHR and healthcare software.
• Commitment to patient-centered, ethical practice.

Responsibilities

• Lead and mentor Utilization Review Nurses.
• Oversee care plan development and coordination.
• Monitor resource utilization and care appropriateness.
• Implement quality improvement initiatives.
• Manage department budget and resources.
• Provide ongoing staff training and development.
• Serve as patient advocate throughout care.
• Ensure timely documentation and regulatory compliance.

Skills

Leadership

Team Management

Care Coordination

Quality Improvement

Budgeting

Staff Development

Patient Advocacy

Documentation

Education

BSN

MSN

Tools

EHR systems

Healthcare software

Job description

The Manager, Utilization Review is responsible for overseeing the daily operations of the Utilization Review for one of our clients and leading a team of Utilization Review Nurses. This role involves ensuring efficient care coordination, managing healthcare costs, and maintaining high-quality patient care standards. The Manager, Utilization Review will collaborate with various healthcare professionals to improve patient outcomes and streamline care processes.

Key Responsibilities

• Leadership and Team Management:
  • Supervise and mentor a team of Utilization Review Nurses, providing guidance and support to ensure excellent performance.
  • Foster a collaborative and cohesive work environment within the department.
  • Conduct regular staff meetings, performance evaluations, and staff development activities.
• Care Coordination and Oversight:
  • Oversee the development and implementation of individualized care plans for patients.
  • Collaborate with the healthcare team to ensure coordinated and efficient patient care across different healthcare settings.
  • Monitor and assess the appropriateness of care plans and resource utilization.
• Quality Improvement:
  • Implement and monitor quality improvement initiatives to enhance patient outcomes and compliance with healthcare regulations.
  • Analyze data and metrics to identify areas for improvement in care coordination processes.
• Budget Management:
  • Manage the department's budget and resource allocation efficiently while maintaining high-quality patient care.
  • Collaborate with finance and administrative teams to optimize resource utilization.
• Staff Development:
  • Provide ongoing training and education to Utilization Review Nurses to keep them updated on best practices and regulatory changes.
  • Encourage professional growth and development within the department.
• Patient Advocacy:
  • Serve as a patient advocate, ensuring that patients' needs and preferences are addressed throughout their healthcare journey.
  • Participate in complex case reviews and offer guidance on challenging patient cases.
• Documentation and Compliance:
  • Ensure accurate and timely documentation of patient records, care plans, and progress notes in accordance with regulatory standards.

Qualifications

• Current RN (Registered Nurse) license. PHRN or USRN, Compact or Multi-State License strongly preferred.
• Bachelor's degree in Nursing (BSN) required; Masters (MSN) preferred.
• Previous experience in case management or care coordination, with at least 2 years in a leadership role.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills.
• Knowledge of healthcare regulations, insurance processes, and quality improvement methodologies.
• Proficiency in electronic health records (EHR) and healthcare software.
• Dedication to patient-centered care and a commitment to ethical practice.

If you are an experienced and visionary nurse leader who is passionate about improving patient care and outcomes, we invite you to apply for the Utilization Review Nurse Manager position. Join our team and lead the way in optimizing patient care. Apply today!