Senior RN Case Management Lead - Utilization Review

Surgery Partners, Inc.; Addison, Northern (TX, KY); Hybrid; USD 95,000 - 135,000; Full time

Job summary

Manager of Case Management at Surgery Partners, Inc. leads the case management team with a strong focus on utilization review, ensuring compliant care and reducing unnecessary hospital stays. This role collaborates across departments to optimize care coordination and outcomes.

Requirements include RN license with BSN, UR/UR-related credentials, and 3+ years hospital-based case management experience. Proficiency with EPIC and payer policies is preferred; leadership and communication skills are

Qualifications

• RN license with BSN is required.
• CCM or ACM certification strongly preferred.
• Familiarity with EPIC and MCG Indicia preferred.
• Minimum 3 years of case management experience in a hospital setting.
• Understand CMS guidelines and payer policies.
• Ability to use InterQual or Milliman for level-of-care decisions.
• Knowledge of coding principles and chargemaster operations.
• Strong communication, organization, and teamwork; supervisory experience preferred.

Responsibilities

• Lead, mentor, and manage the case management team.
• Develop and implement policies to improve efficiency and regulatory compliance.
• Conduct performance evaluations and provide professional development.
• Oversee utilization review to ensure appropriate use of healthcare services.
• Ensure CMS and commercial payer requirements compliance.
• Analyze data to identify trends and recommend process improvements.
• Facilitate transitions of care across the continuum (inpatient, outpatient, home health).
• Collaborate with physicians and clinicians to develop patient-centered care.
• Facilitate discharge planning and care coordination.
• Monitor KPIs (readmissions, LOS, denial management) and regulatory forms.
• Ensure adherence to accreditation standards (DNV, COP) and keep updated on regulations.
• Serve as liaison between case management, clinical staff, and leadership.

Skills

Case management leadership

Utilization Review

CMS guidelines knowledge

InterQual/Milliman

EPIC

Communication skills

Team leadership

Organizational skills

Education

BSN

Tools

EPIC EMR

MCG Indicia

InterQual/Milliman

Job description

Manager of Case Management at Surgery Partners, Inc. leads the case management team with a strong focus on utilization review, ensuring compliant care and reducing unnecessary hospital stays. This role collaborates across departments to optimize care coordination and outcomes.

Requirements include RN license with BSN, UR/UR-related credentials, and 3+ years hospital-based case management experience. Proficiency with EPIC and payer policies is preferred; leadership and communication skills are