Utilization Review Manager: Payer & Compliance Lead

Northwest Texas Healthcare system; South Attleboro (MA); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Student loan repayment

Tuition reimbursement

Generous PTO

Medical, dental, vision

401K match

Career development

Job summary

Fuller Hospital in South Attleboro, MA is seeking a Manager of Utilization Review to oversee utilization management, documentation, payer relationships, and regulatory compliance. This is a full-time, 40-hour-per-week role within a psychiatric facility, contributing to patient care and hospital operations.

The role requires MA licensure (RN/LCSW/LICSW/LMHC) and 3+ years in Utilization Review, with supervisory experience preferred.

Qualifications

• Current Massachusetts licensure as a RN, LCSW, LICSW, or LMHC.
• 3+ years of Utilization Review experience; at least 1 year of direct supervisory experience preferred.
• Knowledge of Insurance procedures and billing terminology.
• Basic knowledge of psychiatric/addiction diagnoses and DSM-V codes with clinical assessment.
• Strong leadership and coaching abilities.
• Problem-solving and time-management skills.
• Experience using data to identify trends and monitor team productivity.
• Familiarity with managed care payer practices and medical necessity determinations.

Responsibilities

• Oversee all utilization management functions.
• Oversee precertification, concurrent, and discharge utilization reviews.
• Ensure regulatory compliance through proper documentation and resource allocation.
• Serve as a key member of hospital management and contribute to financial/clinical outcomes.
• Coordinate with hospital physicians to align payer expectations with patient care needs.
• Lead payer engagement including post-payment reviews, payer audits, and denial/appeal oversight.
• Manage utilization management staff and perform department head duties.
• Perform other duties as assigned.

Skills

Insurance procedures

Billing procedures

DSM-V knowledge

Leadership skills

Time management

Data trends analysis

Managed care

Supervisory experience

Education

Massachusetts licensure (RN/LCSW/LICSW/LMHC)

Job description

Fuller Hospital in South Attleboro, MA is seeking a Manager of Utilization Review to oversee utilization management, documentation, payer relationships, and regulatory compliance. This is a full-time, 40-hour-per-week role within a psychiatric facility, contributing to patient care and hospital operations.

The role requires MA licensure (RN/LCSW/LICSW/LMHC) and 3+ years in Utilization Review, with supervisory experience preferred.