RN Supervisor of Utilization Review - Managed Care
Santa Barbara, CA
Supervisor of Utilization Review Job Summary:
Supervisor of Utilization Review / Utilization Management supports the Manager in overseeing the day-to day operations of the UR/UM staff to ensure all contract requirements and business initiatives are completed successfully and timely.
The role of Utilization Review Supervisor is to promote the quality and cost effectiveness of medical care through auditing the fair and timely resolution of request for specialty referral authorization, monitoring for appropriate application of benefit and providers.
This position is expected to provide training to staff, identify areas for improvement, resolve any staff issues, provide new hire orientation and supervise staff as needed.
The Nurse Supervisor will oversee the medical review of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
This is a working supervisor position, and does carry some responsibility to assist with conduction utilization reviews done on a prospective, concurrent, and retrospective basis.
Supervisor of Utilization Review Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
CCM or CPUR or similar certification is preferred
2 years' acute care clinical nursing experience is required.
2 years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
1+ year experience as a RN in a lead, supervisory or management role is required.
Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.