RN Manager of Utilization Review – Managed Care
Washington D.C. (Downtown)
Manager of Utilization Review Job Summary:
Manager of Utilization Review Background:
- Oversees clinical and non-clinical operations, ensuring fulfillment of all required contractual, legal, and accreditation standards plus compliance with corporate and Care Management policies.
- Manages (and as needed assists) staff that conducts prior authorization reviews, pre-admission reviews, emergency admission reviews, continued stay reviews, retrospective reviews, and long-term care reviews.
- Contributes to, implements, and maintains departmental policies and procedures, staffing protocols, and training programs.
- Manages continuous quality improvement initiatives to improve the delivery, quality, and effectiveness of service delivery.
- Monitors the reliability and consistency of teams' work output to ensure adherence to contract deliverables; collaborates with the Project Director to effectively address issues that are identified.
- Attends monthly performance meetings with the contracting officer’s representative; provides feedback on the findings of the monitoring activities, identifies opportunities for performance improvement, and steps that must be taken to implement initiatives or complete corrective action.
- As needed, may also conduct utilization management reviews, plus other case reviews.
- Valid, unrestricted state Registered Nurse (R.N.) license.
- Requires Bachelor of Science or Arts in healthcare related field; Master’s degree a plus.
- Certified Professional in Healthcare Quality (CPHQ) or Utilization (CPHM/CPUR/CPUM) is highly preferred.
- Around 1-2 years of acute care clinical nursing experience required.
- Requires 3-5 years of Medicaid-specific Utilization Management & Quality Improvement experience.
- Requires proficiency with utilization review, community-based programs, quality improvement, and Medicaid.
- Around 1-3 years of progressive staff supervisionexperience as lead, supervisor, manager within a healthcare environment.
- Experience in training, teaching, and coaching staffs to meet operational requirements and goals.
- Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
- Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.