Utilization Review Manager

Careerwebsite; Billings (MT); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Careerwebsite in Billings, MT seeks a Manager of Utilization Review to oversee cost-effective use of healthcare resources and improve patient outcomes.

The role leads a team, collaborates with medical staff, ensures regulatory compliance, analyzes utilization data, and partners with payers to secure timely reimbursement. Bachelor’s in Nursing and Montana RN license required; 5 years clinical experience; strong leadership.

Qualifications

• Bachelor's degree in nursing required.
• 5 years of experience in a clinical setting.
• Current Montana RN license.

Responsibilities

• Oversee the Utilization Review process to ensure cost-effective use of healthcare resources.
• Develop and implement utilization management strategies and protocols.
• Collaborate with medical staff to evaluate medical necessity and treatment plans.
• Lead and mentor a team of Utilization Review Specialists.
• Analyze utilization data and trends to identify opportunities for efficiency.
• Monitor provider performance and implement corrective action plans.
• Stay updated on regulations, guidelines, and technologies in utilization management.
• Maintain documentation to ensure compliance.
• Collaborate with payers to ensure timely reimbursement.
• Participate in quality improvement initiatives with the Quality Management team.

Skills

Utilization management

Leadership

Data analysis

Regulatory compliance

Team mentoring

Healthcare operations

Education

Bachelor's Degree in Nursing

Tools

Healthcare IT systems

Job description

This position is responsible for overseeing and optimizing the utilization of resources, promoting efficiency and improving patient outcomes. The Manager of Utilization Review plays a crucial role in monitoring the quality of care provided, coordinating with various departments and implementing strategies to minimize costs while maintaining high standards of patient care.

Essential Job Functions

• Oversee the Utilization Review process to ensure the appropriate and cost-effective use of healthcare resources.
• Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
• Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
• Lead and mentor a team of Utilization Review Specialists, providing guidance and support in reviewing patient medical records and gathering relevant clinical information.
• Analyze utilization data and trends to identify opportunities for improving efficiency and reducing unnecessary costs.
• Monitor and assess the performance of healthcare providers, identifying areas for improvement and implementing corrective action plans.
• Stay abreast of changing regulations, guidelines, and technologies in the field of healthcare utilization management, and develop strategies to ensure compliance and enhance operational efficiency.
• Maintain accurate and comprehensive documentation of all utilization review activities, ensuring compliance with organizational policies and regulatory requirements.
• Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
• Participate in the development and implementation of quality improvement initiatives, working collaboratively with the Quality Management team to enhance patient care outcomes.

Minimum Qualifications

Education

4 Year / Bachelors Degree Bachelors Degree in Nursing

Experience

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

Certifications and Licenses

• Current Montana Registered Nurse License