Mgr Utilization Review
The Manager of Utilization Review is responsible for overseeing the utilization review process to ensure the appropriate, efficient, and cost-effective use of healthcare resources. This role supports clinical and financial outcomes by coordinating with medical staff, case managers, and payors, and by implementing strategies that align with Beacon Health System’s mission and regulatory requirements.
MISSION, VALUES and SERVICE GOALS
- MISSION: We deliver outstanding care, inspire health, and connect with heart.
- VALUES: Trust. Respect. Integrity. Compassion.
- SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Leadership & Oversight
- Lead and mentor a team of Utilization Review Nurses.
- Develop and implement utilization management protocols and strategies.
- Ensure compliance with Medicare, Medicaid, and third-party payor requirements.
- Collaborate with the Director of Case Management to align departmental goals.
Utilization review Operations
- Monitor medical necessity of admissions, duration of stays, and services rendered.
- Address authorization challenges and reduce preventable denials.
- Maintain accurate documentation of all Utilization Review activities.
Performance Improvement
- Analyze utilization data to identify inefficiencies and opportunities for cost savings.
- Implement LEAN methodologies to improve Utilization Review processes.
- Prepare reports for oversight committees and leadership.
Education & Staff Development
- Assess learning needs and develop orientation and continuing education programs.
- Validate staff competencies through audits and direct observation.
- Serve as a resource for complex Utilization Review decision-making.
Compliance & Quality Assurance
- Ensure adherence to medical necessity criteria – Xsolis, MCG, and InterQual guidelines.
- Support quality improvement initiatives in collaboration with the Quality team.
- Maintain up-to-date knowledge of healthcare regulations and technologies.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
- Attends and participates in departmental meetings and is accountable for shared information.
- Completes mandatory education, competencies, and department-specific training within required timeframes.
- Meets annual employee health and licensure/certification requirements.
- Maintains required certifications, such as BCLS/CPR, as applicable.
- Uses universal precautions, protective equipment, and ergonomic techniques appropriately.
- Adheres to regulatory, compliance, and survey requirements.
- Complies with organizational and departmental policies and is available to work flexible schedules and overtime as needed.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.
Leadership Competencies
- Drives Results - Consistently achieving results, even under tough circumstances.
- Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
- Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
- Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
- Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
Education and Experience
- Bachelor’s Degree in Nursing required; Master’s in Nursing, Healthcare Administration, or related field preferred.
- Current RN license in the state of Indiana.
- Minimum 3–5 years of experience in utilization review or case management.
- Prior supervisory or management experience strongly preferred.
Skills & Competencies
- Strong analytical and critical-thinking skills.
- Excellent communication and interpersonal abilities.
- Proficiency in healthcare software and electronic health records.
- Knowledge of reimbursement methodologies.
- Ability to lead change and foster a culture of continuous improvement.
Working Conditions
- Works in an office environment
Physical Demands
- Requires the physical ability and stamina to perform the essential functions of the position.
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