Job Description


Job Description
Minimum Qualifications:
RN CA License required - Graduate of an accredited school of nursing.
Five or more year's clinical experience is required.
Three to five years Utilization Management experience required.
One to three years charge/lead/supervisory/management experience required.
Ability to demonstrate leadership and management skills.
7 years UM experience with Charge/Lead/Supervisory/Management experience in the Utilization Management department.
Experience working with health plan auditors.
Bachelor of Science in Nursing and/or master’s level degree preferred
Working knowledge of InterQual. Knowledgeable of NCQA and ICE.
 
Duties:
Lead and supervise a team of utilization management nurses, providing guidance, support, and oversight.
Develop and implement departmental policies, procedures, and protocols to ensure efficient utilization review processes.
Coordinate staffing assignments, schedules, and workload distribution within the utilization management team.
Conduct performance evaluations, provide feedback, and identify training needs for staff members.
Serve as a resource and mentor for utilization management nurses, offering clinical expertise and guidance in complex cases.
Collaborate with other departmental supervisors and managers to streamline processes and enhance interdisciplinary communication.
Monitor team performance metrics and outcomes, identifying areas for improvement and implementing corrective actions as needed.
Ensure compliance with regulatory requirements, accreditation standards, and organizational policies related to utilization management.
Participate in the development and implementation of quality improvement initiatives to optimize healthcare delivery and outcomes.
Foster a culture of continuous learning, professionalism, and collaboration within the utilization management team.
Serve as a liaison between the utilization management team and other departments, stakeholders, and external entities.
Stay informed about current trends, best practices, and innovations in utilization management and healthcare delivery.
 

Education: Masters Degree

Application Instructions

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