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RN Manager of Utilization Review

Fort Lauderdale, FL · Healthcare
RN Manager of Utilization Review - Managed Care
Ft Lauderdale, FL

Manager of Utilization Review Job Summary:
  • Manage the day to day operations of the utilization management function. 
  • Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
  • Promote compliance with federal and state regulations and contractual agreements.
  • Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
  • Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
  • Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
  • Facilitate on-going communication between utilization management staff and contracted providers.
  • Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
Manager of Utilization Review Background:
  • Current, valid, and unrestricted state Registered Nurse (R.N.) license.
  • Bachelor degree in Nursing or related field, and/or certification as CCM, CPUR/CPUM/CPHM, CPHQ or similar is preferred
  • Around 2-3 years acute care clinical nursing experience is required.
  • Requires around 3-5 years of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
  • At least 1-2 years 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.
  • Must be willing and able to travel locally, if needed.

480.269.9491 (CALL – TEXT – FAX)
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