[Hiring] Utilization Review Manager @Ensemble Health Partners

Role Description

The Manager for Utilization Review is responsible for the leadership and management of the centralized Virtual Utilization Management Program and maintaining the support structure within the department for achieving clinical and operational excellence. Key responsibilities include:

• Overseeing authorization, denials, and appeals of inpatient and observation or outpatients.
• Assuming system program compliance, program development, and strategy responsibilities.
• Collaborating with local market hospital-based UM leaders and physician advisors.
• Working with Coding, Care Coordination, Clinical Documentation Specialists, and Health Information Management.
• Collaborating extensively with other members of the health care team to provide data and solution development processes.

Qualifications

• 2 Year/ Associates Degree in Nursing (Preferred: 4 Year/ Bachelor's Degree in Nursing).
• Current unrestricted license to practice nursing in the resident State.
• MCG Certification required within 6 months of hire.

Requirements

• Demonstrated advanced usage of AI and management of teams using AI.
• Proficient in negotiating complex systems to effect positive change.
• Proficient in communicating clearly and effectively with multiple constituents.
• Proficient on computer usage, especially database and spreadsheet analysis.
• Broad knowledge and skilled use of MCG or nursing criteria guidelines.
• Broad knowledge of insurance regulations and Medicare and Medicaid guidelines.
• Ownership of UM staff annual employee engagement with active action plan to address issues.
• Develop departmental budget with Director of Utilization Management and AVP of Utilization Management.
• Review monthly department budget reports and design action plan to address budget variances.

Benefits

• Bonus Incentives.
• Paid Certifications.
• Tuition Reimbursement.
• Comprehensive Benefits.
• Career Advancement.