RN Manager of Utilization Review – Managed Care
Washington D.C. (Downtown)
 
Manager of Utilization Review Job Summary:
 

• 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. 

 
Manager of Utilization Review Background:
 

• 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. 

#CLINICAL
 
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