Registered Nurse-Manager of Utilization Management, Full Time Days

capefearvalley; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Cape Fear Valley Health System in Fayetteville, NC, seeks a Manager of Utilization Management within Coordination of Care. The role oversees RN staff, ensures compliant denials management and timely appeals, and partners with payers and clinical teams to optimize patient care and costs.

You will lead policy reviews, educate staff, and drive performance improvement while aligning with Joint Commission and Medicare/Medicaid rules. Relocation assistance is available.

Qualifications

• Associate's degree in Nursing required.
• Bachelor's degree in Nursing preferred.
• Current RN licensure in North Carolina or Compact state licensure required.
• 3 years' Utilization Management experience required.
• 1 year Case Management experience preferred.
• 1 year data analysis experience preferred.
• 3 years in managed care claims/reimbursement or related healthcare field preferred.
• Must have management experience in Utilization Review.
• Must understand revenue cycle.
• Must understand Epic and Epic reporting.

Responsibilities

• Leads, coordinates and oversees the workload of the UM RNs.
• Reviews and recommends policies and procedures related to UM.
• Maintains updated knowledge of Medicare/Medicaid regulation changes and communicates new processes.
• Audits staff's Admission and Concurrent Reviews for accurate criteria.
• Provide education to staff from data analysis and trends.
• Responds to demand letters from payers, ensuring appeal timeframes are met.
• Serves as Medical Necessity Reviewer with Physician Advisor.
• Educates on Joint Commission requirements, audits, and record maintenance.
• Identifies opportunities to improve UM processes to meet evolving needs.
• Other duties as assigned.

Skills

Leadership

Communication

Analytical skills

Time management

Negotiation

Data management

Research skills

Education

Associate's degree in Nursing

Bachelor's degree in Nursing preferred

RN licensure in NC or Compact state

Tools

EPIC

EPIC Reporting

InterQual

MCG

Microsoft Office

Teams

Webex

Job description

RELOCATION ASSISTANCE AVAILABLE!!

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Coordination of Care

Job Family

Management

Work Shift

Days (United States of America)

Summary

Participates 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 Functions

• Leads, coordinates and oversees the workload of the Utilization Management RNs
• Reviews and recommends policies and procedures in relation to Utilization Management
• Maintains 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 activities
• Audits staff's Admission and Concurrent Reviews for accurate application of criteria
• Provide education to staff as a result of comprehensive analysis of data gathered and trends identified
• Responds proactively to demand letters received from all payers, ensuring that contacted timeframes for appeals are met
• Serves as Medical Necessity Reviewer in conjunction with Physician Advisor for Recovery Audit Contractor Team
• Educates on and facilitates compliance with Joint Commission requirements, audits, compliance, and record maintenance
• Identifies and develops department and individual performance audit tools to measure compliance and quality
• Identifies opportunities and solution sets and strategies to improve utilization management departmental processes to meet the evolving needs of specific patient populations, hospital, and community

Other duties as assigned

Minimum Qualifications

The 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 required
• Bachelor's degree in Nursing preferred
• Current Registered Nurse licensure in North Carolina or Compact state licensure required

Work Experience :

• 3 years' experience in Utilization Management required
• 1 year of Case Management experience preferred
• 1 year prior experience with data and statistical analysis preferred
• 3 years in managed care claims/reimbursement or other healthcare field preferred
• Must 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 language
• Knowledge of professional nursing principles, clinical processes, and clinical interventions
• Working knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory services
• Ability to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical records
• Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
• Knowledge and ability to implement a quality improvement process
• Strong analytic, data management and research skills
• Excellent interpersonal communication and negotiation skills
• Ability to communicate effectively and work with people of all social, economic, and cultural background
• Self-motivated, proven written, telephonic, and electronic communication skills
• Assertive and persuasive interactions with customers, peers, management, and core staff served
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Understanding of criteria and measurement outcomes
• Knowledge of third-party payor requirements including managed care, reimbursement and utilization management
• Proficiency with various computer programs, to include Microsoft Office, EPIC, InterQual, MCG, Teams, Webex
• Working knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, Criteria-Based Management
• Ability to demonstrate leader