Manager, Utilization Management - Registered Nurse (Remote)

Summary of Position

Manage the utilization review process, ensuring that healthcare services are medically necessary, appropriate, and costeffective. Oversee the day-to-day operation and performance of specific functional areas within the compliance with health plans 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.