RN Supervisor of Utilization Review - Managed Care
La Cross, WI
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.
As needed, conduct and perform medical case management functions such as initial assessment, development of plan of care and ongoing management.
Supervisor of Utilization Review Background:
Current, valid, and unrestricted state Registered Nurse (R.N.) license.
Prefer additional RN licensure in nearby states (MN and/or IL)
CCM or CPUR or similar certification is preferred
2 years acute care clinical nursing experience is required.
Requires 2 years of recent experience in Utilization Review or Utilization Management in a clinical and/or inpatient setting.
Around 1-year of experience as a RN in a lead, supervisory or management role is required.
Prefer 1+ years at a health plan or other managed care organization (HMO/TPA/IPA/etc).
Knowledge of guidelines for NCQA/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.
Working knowledge of managed care as it relates to contracting in health insurance, DRG’s, CPT, ICD-9, HCSPCS coding.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.