Rn Manager Utilization Review Management

MedStar Health; Washington (District of Columbia); On-site; USD 103,000 - 197,000; Full time

Job summary

MedStar Health seeks a senior manager for Utilization Management to lead clinical review of acute services, ensure medical necessity and appropriate discharge planning, and coordinate care across teams. The role emphasizes collaboration with interdisciplinary staff to optimize outcomes and resource use.

The position requires RN licensure, CCM certification, and a strong background in utilization management, population health, and regulatory compliance within a hospital system.

Qualifications

• Bachelor's degree from an accredited school of nursing.
• 3-4 years Utilization management experience.
• 5-7 years Diverse clinical experience.
• 1-2 years Supervisory experience.

Responsibilities

• Contributes to department goals and adheres to policies and safety standards.
• Leads validation of medical necessity using criteria and guidelines.
• Acts as liaison between IS and clinical teams to identify workflow issues.
• Analyzes UM monthly reports and reports trends to the Director.

Skills

Verbal communication

Written communication

Excel proficiency

PowerPoint

Education

Bachelor's degree in nursing

Tools

Microsoft Office

Job description

About the Job

General Summary of Position

Responsible for evaluating the necessity appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute services for appropriateness based on medical criteria the management of healthcare resources necessary and appropriate for achievement of desired outcomes and the coordination of alternative levels of care for enrollees/members. Works collaboratively with interdisciplinary staff both internal and external to the organization to facilitate the continuum of care through education and advocacy to enhance health outcomes.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Actively leads the process of validating medical necessity by utilizing pre-approved criteria and guidelines for continued stay and appropriateness of treatment and discharge planning.
• Acts as a liaison between IS and the clinical team to identify workflow / system issues and resolutions. Uses technology to enhance decision making and effectiveness.
• Analyzes the UM monthly reports on LOS Days per 1000 readmissions physician denials denial rates at acute facilities productivity and other reports as required by MFC Clinical Operations. Reports trends/findings to the Director on at least a monthly basis.
• Assists staffs with setting personal and educational goals and objectives to enhance their professional development. Develops and implements education programs to coordinate staff development and training needs both for software and clinical training issues.
• Assists with hiring training orientation and assignments of department staff. Assists with the development and evaluation of performance standards. Initiates or makes recommendations for personnel actions. Maintains regular ongoing communication with subordinates to review progress provide feedback discuss new developments and exchange information.
• Collaborates with the Director and contributes to the achievement of department goals and objectives and adheres to department policies procedures quality standards and safety standards.
• Direct management of the Utilization Management Team to assure and maintain high quality and productivity standards; ensure results-oriented utilization management timely customer service follow-up and strong communication skills.
• Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
• Demonstrates skill and flexibility in providing coverage for staff and other department managers.
• Educates and monitors staff regarding timely and accurate documentation in the clinical software system per Clinical Operations policies.
• Ensures compliance with governmental and accreditation regulations.
• Leads staff meetings weekly census work groups etc. as assigned. Addresses issues impacting MFC with community agencies and providers. Delivers updated information back to department staff.
• Maintains current knowledge and functions as a resource to the clinical team regarding benefits authorizations enrollment issues practice guidelines and alternative treatment options in order to accurately coordinate enrollees/provider services.
• Manages ACD telephone coverage and processes related to PCP and provider questions eligibility and benefits transportation and authorization issues.
• Monitors and ensures compliance with UM standards as per MFC policies and procedures.
• Performs other duties as assigned.
• Provides backup support in the absence of the Director as required. Works in partnership with the Manager of Case Management and other Managers as appropriate in development of the annual Clinical Operations Plan and the Clinical Operations Appraisal.
• Provides continuing individual coaching and support to staff and acts as a resource for clinical social utilization and appeal review issues as they relate to the Clinical Operations department.
• Serves as a first line intermediary in inter-associate disagreements; knowing when to escape issues to the next level of management.

Minimal Qualifications

Education

• Bachelor's degree from an accredited school of nursing or equivalent combination of education and experience required or

Experience

• 3-4 years Utilization management experience required and
• 5-7 years Diverse clinical experience required and
• 1-2 years 2 years Supervisory experience required

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN License in the State of Maryland Maryland CCM (Certified Case Manager) required or
• CCM - Certified Case Manager Valid RN License in the State of Maryland Maryland CCM (Certified Case Manager) required
• achievement within 2 years of assuming the Manager position. required

Knowledge Skills and Abilities

• Excellent verbal and written communication skills.
• Ability to follow verbal and written instructions.
• Proficient computer with Microsoft Office applications especially Word Excel and PowerPoint.
• Ability to enter and retrieve information using a PC.
• Working knowledge of various computer software applications.
• Knowledge of current trends in health care delivery and population management.
• Knowledge of NCQA HEDIS InterQual and local regulatory guidelines preferred.

This position has a hiring range of USD $102,606.00 - USD $196,996.00 /Yr.