Registered Nurse-Manager of Utilization Management, Full Time Days

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Relocation assistance available

Job summary

Cape Fear Valley Health System seeks a forward-thinking Utilization Management leader in Fayetteville, NC. The role oversees UM workload, policy adherence, and staff development, ensuring timely denials management and payer communications.

You will collaborate with physicians, nurses, and stakeholders to optimize patient care and cost containment. Experience in UM, data analytics, and regulatory knowledge is essential, with a focus on Medicare/Medicaid guidelines and Joint Commission standards.

Qualifications

• Associate degree in Nursing required.
• RN license in North Carolina or compact state.
• Bachelor's degree in Nursing preferred.

Responsibilities

• Lead and oversee the Utilization Management workload and staff.
• Review policies and procedures to ensure compliance with Medicare/Medicaid and regulations.
• Audit admissions and concurrent reviews for criteria accuracy.
• Educate staff based on data analysis and trends.
• Respond to demand letters and manage payer appeals timelines.
• Serve as Medical Necessity Reviewer with Physician Advisor for the RAC team.
• Educate on Joint Commission requirements, audits, and record maintenance.
• Develop tools to measure compliance and drive quality improvement.
• Collaborate across departments to optimize patient care utilization.

Skills

Utilization Management

Leadership

Data analysis

Policy development

Communication

Quality improvement

Team management

Education

Medicare guidelines

Joint Commission

Education

Associate degree in Nursing

Bachelor's degree in Nursing (preferred)

Tools

Epic

InterQual

MCG

MS Office

Job description

RELOCATION ASSISTANCE AVAILABLE!!FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentCoordination of CareJob FamilyManagementWork ShiftDays (United States of America)SummaryParticipates in and oversees the operational and personnel activities as it relates to Utilization Management needs and requirements. Responsible for the coordination and management of denials and subsequent outgoing appeals between payers and Cape Fear Valley Health System. Supports a collaborative coordinated process among departments within the community, health system, physician, and support staff to promote effective management and cost containment of patient care across the healthcare continuum. Fosters teamwork and integration of services for the staff in Coordination of Care and the customers served. Adheres to patient experience initiatives and champions customer service excellence.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Leads, coordinates and oversees the workload of the Utilization Management RNsReviews and recommends policies and procedures in relation to Utilization ManagementMaintains updated knowledge of Medicare and Medicaid regulation changes and provides communication and facilitates new process changes as necessary to maintain compliance as it relates to Utilization Management activitiesAudits staff’s Admission and Concurrent Reviews for accurate application of criteriaProvide education to staff as a result of comprehensive analysis of data gathered and trends identifiedResponds proactively to demand letters received from all payers, ensuring that contacted timeframes for appeals are metServes as Medical Necessity Reviewer in conjunction with Physician Advisor for Recovery Audit Contractor TeamEducates on and facilitates compliance with Joint Commission requirements, audits, compliance, and record maintenanceIdentifies and develops department and individual performance audit tools to measure compliance and qualityIdentifies opportunities and solution sets and strategies to improve utilization management departmental processes to meet the evolving needs of specific patient populations, hospital, and communityOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Associate’s degree in Nursing requiredBachelor's degree in Nursing preferredCurrent Registered Nurse licensure in North Carolina or Compact state licensure requiredWork Experience:3 years’ experience in Utilization Management required1 year of Case Management experience preferred1 year prior experience with data and statistical analysis preferred3 years in managed care claims/reimbursement or other healthcare field preferredMust have management experience in Utilization Review, experience with insurance claims.Must have an understanding of working with a revenue cycle.Must understand Epic and Epic reporting.Must be able to build reports to manage staff and improve upon an already standing UM committee.This position requires working every 4th or 5th weekend.Knowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageKnowledge of professional nursing principles, clinical processes, and clinical interventionsWorking knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory servicesAbility to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical recordsKnowledge of clinical practice guidelines and the appropriateness of clinical interventionsKnowledge and ability to implement a quality improvement processStrong analytic, data management and research skillsExcellent interpersonal communication and negotiation skillsAbility to communicate effectively and work with people of all social, economic, and cultural backgroundSelf-motivated, proven written, telephonic, and electronic communication skillsAssertive and persuasive interactions with customers, peers, management, and core staff servedStrong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role componentsUnderstanding of criteria and measurement outcomesKnowledge of third-party payor requirements including managed care, reimbursement, and utilization managementProficiency with various computer programs, to include Microsoft Office, EPIC, InterQual, MCG, Teams, WebexWorking knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, Criteria-Based ManagementAbility to demonstrate leadership, respect, and team buildingFlexible, open-minded, and adaptable to changePhysical Requirements:Some light carrying and lifting may be requiredOccasional walking may be required to access all areas of the Medical CenterAbility to effectively communicate orally with patients, family members, personnel, and physiciansNear visual acuity to proofread hand or typewritten materialsManual ability to use telephones and computer keyboardPosition involves sitting for extended periods of time performing data entry into a computer#CFVH-2026Required Licenses and CertificationsCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity