Market Manager Utilization Review

Santa Barbara Cottage Hospital; United States; Remote; USD 80,000 - 110,000; Full time

Job summary

An established healthcare provider is seeking a Utilization Management Manager to lead operations in Arizona and Nevada. This role is vital for ensuring effective team management and adherence to regulatory standards. The ideal candidate will possess a strong background in clinical case management and demonstrate excellent leadership skills. Join a respected institution dedicated to providing quality care and support to the community. This position offers opportunities for professional growth and development, along with a comprehensive benefits package, including education assistance to help you achieve your career goals.

Benefits

Education Benefit Program

Debt Relief Assistance

Student Loan Assistance

Qualifications

• 5+ years in clinical case management with a focus on UM and denial management.
• Strong knowledge of Medicare, Medicaid, and commercial review requirements.

Responsibilities

• Manage daily operations of care coordination and staff supervision.
• Oversee staff recruitment and ensure compliance with policies.

Skills

Utilization Management

Clinical Case Management

Denial Management

Care Coordination

Healthcare IT Systems

Leadership Skills

Communication Skills

Organizational Skills

Education

Bachelor's degree in Nursing

Master's degree in Nursing

Tools

Healthcare IT Systems

Job description

Overview

Hello humankindness

Located conveniently in the heart of Phoenix, Arizona, St. Joseph's Hospital and Medical Center is a 571-bed, not-for-profit hospital that provides a wide range of health, social and support services. Founded in 1895 by the Sisters of Mercy, St. Joseph's was the first hospital in the Phoenix area. More than 125 years later, St. Joseph's remains dedicated to its mission of caring for the poor and underserved.

We are extremely proud to be a nationally recognized center for quality quaternary care, medical education and research. St. Joseph's includes the internationally renowned Barrow Neurological Institute, Norton Thoracic Institute, Cancer Center at St. Joseph's, Ivy Brain Tumor Center, and St. Joseph's Level I Trauma Center (verified by the American College of Surgeons). The hospital is also a respected center for high-risk obstetrics, neuro-rehabilitation, orthopedics, and other medical services. St. Joseph’s is considered a sought-after destination hospital for treating the most complex cases from throughout the world. Every day, approximately 20 percent of the hospital’s patients have traveled from outside of Arizona and the United States to seek treatment at St. Joseph’s.

U.S News & World Report routinely ranks St. Joseph's among the top hospitals in the United States for neurology and neurosurgery. In addition, St. Joseph's boasts the Creighton University School of Medicine at St. Joseph's, and a strategic alliance with Phoenix Children's Hospital.

St. Joseph's is consistently named an outstanding place to work and one of Arizona's healthiest employers. Come grow your career with one of Arizona's Most Admired Companies.

Look for us on Facebook and follow us on Twitter.

For the health of our community ... we are proud to be a tobacco-free campus.

Responsibilities

This role is for the Arizona and Nevada markets. Must have current Arizona and Nevada unrestricted RN license.

The Utilization Management (UM) Manager is responsible for managing day-to-day UM operations within the markets, focusing on effective team management, authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. Act as a working manager within Utilization Management, performing essential duties and responsibilities (utilization reviews, denials, and authorizations) in non-represented markets, with a time allocation of no more than 40% of the total work hours. Ensure a balance between management and operational responsibilities to maintain effective team leadership and oversight. This role supports the UM Director in ensuring efficient operations with all processes, policies, strategies and ensuring compliance with all regulatory and payer requirements.

Responsibilities:

• Assist with daily operations of care coordination, including effective staff supervision, and resource allocation to align with organizational goals.
• Oversee staff recruitment, performance evaluation, coaching, mentoring, and professional development, ensuring a high-performing team aligned with organizational objectives.
• Oversee daily operations to ensure effective utilization reviews, strict adherence to denial management processes, and compliance with established policies and procedures.
• Ensure prompt and accurate processing of payer communications and authorizations through efficient management by the UM staff.
• Train and mentor UM staff to promote high performance and adherence to regulatory and organizational standards.

Dignity Health offers an Education Benefit program for benefit-eligible employees after 180 days, providing debt relief and student loan assistance to help achieve your goals. Full-time employees can receive up to $18,000 over five years, and part-time employees up to $9,000.

Qualifications

Minimum:

• Bachelor's degree in Nursing, Health Care Administration or related clinical field
• Minimum 5 years of clinical case management (Utilization Management, Denial Management, Care Coordination)
• Minimum 3 years management experience in a clinical case management department (Utilization Management, Denial Management, Care Coordination)
• Current unrestricted Arizona and Nevada RN license
• National certification of CCM (Certified Case Manager), ACM (Accredited Case Manager), required or within 2 years upon hire.

Knowledge and skills:

• Comprehensive knowledge of utilization management
• Medicare, Medicaid, and commercial admission and review requirements
• In-depth knowledge of utilization management processes and best practices
• Strong managerial and decision-making skills
• Excellent communication skills and the ability to work collaboratively.
• Proficient in healthcare IT systems relevant to utilization management
• Effective leadership and team-building skills
• Excellent organizational and communication skills
• Ability to work under pressure and manage multiple priorities
• Knowledge of CMS standards and requirements
• Ability to work as a team player and assist other members of the team where needed.

Preferred qualifications:

• Master's degree in Nursing, Healthcare Administration or related clinical field.
• Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services