MANAGER OF UTILIZATION REVIEW

Southwest General; Middleburg Heights (OH); Vor Ort; USD 95.000 - 125.000; Vollzeit

Zusammenfassung

Southwest General is seeking an Utilization Management RN Manager to lead the UM nursing team and translate strategy into daily execution. You will supervise, coach, and manage workflows while coordinating with physicians, case management, revenue cycle, payer relations, quality and compliance to ensure timely and evidence-informed decisions.

Ideal candidates have 5+ years of clinical/nursing or UM experience, 2+ years in leadership, and an Ohio nursing license.

Qualifikationen

• BSN required or equivalent per policy.
• Master’s degree preferred (Nursing, Healthcare Admin, Business, Public Health or related).
• Five+ years of progressive clinical nursing or UM experience; 3+ years in UM or related fields.
• Prior formal leadership experience; 2+ years of supervisory/management experience preferred.
• Current Ohio State Board of Nursing license required.
• Knowledge of UM and utilization review principles, including prospective, concurrent and retrospective review.
• Ability to interpret analytics, drive process improvement, and communicate across disciplines.

Aufgaben

• Lead day-to-day leadership and performance management of the UM nursing team.
• Provide supervision, coaching, and workflow management for assigned UM staff.
• Collaborate with physician advisors, case management, revenue cycle, payer relations, quality and compliance.
• Translate department strategy and payer requirements into daily execution.
• Support timely, accurate utilization management decisions and resource stewardship.

Kenntnisse

People leadership

Coaching

Performance management

Conflict resolution

Change management

Ausbildung

BSN or equivalent

Master’s degree in Nursing/Healthcare Admin/Business

Jobbeschreibung

The Utilization Management (UM) RN Manager is responsible for the day-to-day leadership, operational oversight, and performance management of the Utilization Management nursing team. Reporting to the UM RN Director, the Manager translates department strategy, regulatory and payer requirements, approved clinical review criteria, and organizational priorities into consistent daily execution.

The role provides direct supervision, coaching, workflow management, clinical-operational support, and performance oversight for assigned UM staff. The Manager collaborates with physician advisors/medical directors, case management, clinical operations, revenue cycle, payer relations, quality, compliance, and other stakeholders to support timely, accurate, evidence-informed utilization management decisions and appropriate stewardship of healthcare resources.

MINIMUM QUALIFICATIONS

Education:

Bachelor of Science in Nursing (BSN) required, or equivalent qualification consistent with organizational policy.

Master’s degree in Nursing, Healthcare Administration, Business Administration, Public Health, or a related field preferred.

Required length and type of experience:

Five or more years of progressive clinical nursing and/or utilization management experience preferred, including three or more years of experience in utilization management, utilization review, case management, managed care, or a closely related function.

Prior formal leadership experience required; two or more years of supervisory or management experience preferred.

Required licensure, certification or registry:

Current Ohio State Board of Nursing license required.

Core Knowledge, Skills, and Competencies

Knowledge of utilization management and utilization review principles, including prospective, concurrent, and retrospective review.

Knowledge of medical necessity, patient status, level-of-care review, authorization processes, payer requirements, denial prevention, and escalation pathways.

Knowledge of evidence-based clinical review criteria and appropriate use of clinical decision-support tools.

Knowledge of regulatory and accreditation requirements affecting utilization management and clinical review.

Demonstrated ability in people leadership, coaching, performance management, conflict resolution, and change management.

Demonstrated ability to interpret operational analytics and KPIs, conduct root-cause analysis, and drive process improvement.

Demonstrated ability to communicate effectively across interdisciplinary teams, including nursing, physicians, physician advisors, payers, revenue cycle, and leadership.

Demonstrated application of professional nursing judgment, ethical practice, confidentiality, and appropriate stewardship of healthcare resources.