Utilization Review & Care Optimization Lead

American Case Management Association, Inc.; Billings (MT); On-site; USD 90,000 - 120,000; Full time

Job summary

American Case Management Association, Inc. is seeking a Manager of Utilization Review to oversee and optimize resource use, promote efficiency, and improve patient outcomes in Billings, MT.

This leadership role coordinates with medical staff and departments, mentors UR specialists, analyzes utilization data, ensures compliance with regulations, and drives quality improvement initiatives while maintaining thorough documentation.

Qualifications

• Bachelor's degree in Nursing
• 5 years of Experience in a clinical setting
• Experience with healthcare information systems and software
• Previous management or supervisory experience

Responsibilities

• Oversee the Utilization Review process to ensure the appropriate and cost-effective use of healthcare resources while maintaining care quality.
• Develop and implement utilization management strategies and protocols in line with industry best practices and regulatory requirements.
• Collaborate with medical staff, case managers, and other healthcare professionals to evaluate medical necessity and appropriateness of treatment plans.
• Lead and mentor a team of Utilization Review Specialists, providing guidance in reviewing patient records and gathering clinical information.
• Analyze utilization data and trends to identify opportunities to improve efficiency and reduce unnecessary costs.
• Monitor and assess provider performance, identifying areas for improvement and implementing corrective action plans.
• Stay updated on changing regulations, guidelines, and technologies in utilization management to ensure compliance and efficiency.
• Maintain thorough documentation of all utilization review activities per policies and regulations.
• Collaborate with insurance companies and government agencies to ensure timely reimbursement and resolve related issues.
• Participate in quality improvement initiatives with the Quality Management team to enhance patient care outcomes.

Education

Bachelors Degree in Nursing

Job description

American Case Management Association, Inc. is seeking a Manager of Utilization Review to oversee and optimize resource use, promote efficiency, and improve patient outcomes in Billings, MT.

This leadership role coordinates with medical staff and departments, mentors UR specialists, analyzes utilization data, ensures compliance with regulations, and drives quality improvement initiatives while maintaining thorough documentation.