Nurse Manager, Utilization Management (Remote)

Summary of Position

Manage the utilization review process, ensuring that healthcare services are medically necessary, appropriate, and cost-effective. Oversee the day-to-day operation and performance of specific functional areas within compliance with health plan policies, procedures, and all regulatory mandates. Manage the supervision of clinical Utilization Management (UM) staff.

Principal Accountabilities

• Manage the day-to-day activities of the clinical UM teams by providing guidance and leadership.
• Oversee accuracy and production of cases with regulatory and accreditation mandates.
• Ensure the delegation of cases across staff to meet set timeframes.
• Identify areas of clinical issues that need corrective action and implement changes needed.
• Manage, train, and oversee daily supervision of clinical staff.
• Create a collaborative, flexible environment within the department.
• Oversee the supervision of staff to complete JMAC specific processes accurately and efficiently within specific contract requirements.
• Track and evaluate data related to utilization patterns, identifying trends, and developing strategies to address areas for improvement.
• Represent Concurrent Review and JMAC function in meetings with internal leaders, other departments, and senior leadership.
• Work with medical staff, case managers, and other healthcare professionals to coordinate care and resolve any utilization-related issues.
• Enforce and adhere to all company and department policies and procedures in confidentiality, regulatory or contractual mandates, and HR policy.
• Serve as lead for clinical rounds in coordination with a Medical Director.
• Represent the department head at meetings as necessary.

Qualifications

• Bachelor’s Degree
• Registered nurse with an active, unrestricted license or certification
• 5 – 8+ years relevant, professional clinical work experience
• 5+ years management experience in health care setting, preferably in managed care
• Knowledge of Utilization Management, HMO operations, and work processes
• Knowledge of New York State and Federal regulatory requirements
• Proficient with MS Office
• Strong communication skills