RN Manager, Regional Utilization Management - Pre-Service
Navigating the Hiring Process
We're here to support you!
Having trouble with your account or have questions on the hiring process?
Please visit the FAQ page on our website for assistance.
Need help with your computer and browser settings?
Do you need a reasonable accommodation due to a disability?
A reasonable accommodation is any modification or adjustment that enables you to fully participate in completing the following:
- Online Submissions
- Pre-Hire Assessments
- Interview Process
Please submit your accommodation request and an HR Representative will contact you.
- Manages the clinical team and or teams that complete medical necessity reviews for authorization and concurrent requests.
- Responsible for the planning and decision-making related to utilization review.
- Develops and implements departmental policies and procedures. Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
- Manages monitoring of staff workload, reviews productivity, and conducts quality reviews.
- Maintains daily oversight of authorization review work queues, and assignments with staff daily to insure appropriate coverage.
- Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefit and clinical criteria.
- Develops and reviews medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, effectiveness, and safety of medical services to achieve favorable healthcare outcomes.
- Work in partnership with the Utilization Management Physicians on affordability and cost initiatives to reduce inappropriate and or over utilization of medical and or behavior health services.
- Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met. Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits, as necessary.
- Manages and oversees the utilization review management training and education program for Utilization Review staff across the region. Ensures post-course evaluation tools and other materials are developed. Manages training and education schedules. Ensures performance measures are developed and staff is managed to such measures consistently and appropriately. Serves as Subject Matter Expert (SME) for Utilization Review workflow issues, complex cases, denials, and internal/external customers.
- Manages including hiring, training, performance evaluations and terminations.
- Facilitates on-going communication among Utilization Review staff, internal providers, and external/contracted providers.
- Minimum three (3) years of clinical and medical utilization/review management experience.
- Associate degree in Nursing with current unrestricted license and/or, Masters degree in social work.
- High School Diploma or General Education Development (GED) required.
- Registered Nurse License (Colorado) OR Licensed Social Worker (Colorado)
- Thorough knowledge of utilization management and clinical practice.
- Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
- Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).
- Recent clinical experience in a hospital, LTACH, AIR or SNF setting preferred.
- Bachelors degree in nursing preferred.
- Case Management Certification preferred.
M-F schedule with one weekend a month on call - Work is currently being performed virtually.