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RN Manager of Utilization ReviewFort Lauderdale, FL · Healthcare
RN Manager of Utilization Review - Managed Care
Ft Lauderdale, FL
Manager of Utilization Review Job Summary:
Manager of Utilization Review Background:
- 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.
- 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.