Utilization Review Manager

Overview

Join our dynamic healthcare team as a Utilization Review Manager, where you will lead and coordinate clinical review processes to ensure optimal patient care while maintaining compliance with healthcare regulations and standards. This pivotal role involves managing a skilled team of clinical professionals, overseeing utilization review activities across diverse care settings, and ensuring adherence to industry best practices. Your expertise will help streamline patient assessments, discharge planning, and documentation review, ultimately supporting efficient healthcare delivery and cost-effective resource utilization.

Duties

• Lead and supervise a multidisciplinary clinical review team, including nurses, social workers, and other healthcare professionals, fostering a collaborative environment focused on quality patient care.
• Oversee the utilization review process for acute care, behavioral health, hospice, home health, and other healthcare services to ensure appropriate level of care and resource allocation.
• Review medical records, documentation, and patient assessments to verify compliance with NCQA standards, HIPAA regulations, and federal/state healthcare policies such as Medicare and Medicaid requirements.
• Coordinate discharge planning efforts by evaluating patient needs, facilitating communication among care teams, and ensuring timely transition of care.
• Develop and implement care plans based on comprehensive patient assessments that incorporate physiology knowledge, mental health counseling insights, and behavioral health considerations.
• Collect data related to utilization metrics, analyze trends, prepare reports for management, and recommend process improvements to enhance clinical efficiency.
• Ensure team adherence to documentation review protocols while maintaining high standards for medical terminology accuracy and anatomy/physiology understanding.

Experience

• Proven management experience leading clinical teams within hospital or healthcare settings.
• Extensive utilization review experience in Level I or Level II trauma centers; ICU experience is highly desirable.
• Background in hospital medicine, emergency medicine, pediatrics—including PICU—and behavioral health environments such as addiction counseling or mental health therapy.
• Strong knowledge of health regulation policies including NCQA standards, HIPAA compliance, Medicare/Medicaid regulations, and managed care frameworks.
• Demonstrated ability to manage complex case management activities involving social work, nursing leadership, discharge planning, and clinical documentation review.
• Familiarity with managing patients as a nurse case manager or similar roles in acute or outpatient settings.
• Excellent leadership skills with experience supervising multidisciplinary teams; capable of fostering team management excellence in fast-paced environments.
• Deep understanding of medical terminology, anatomy, physiology concepts relevant to diverse patient populations including pediatrics and behavioral health.

This role offers an exciting opportunity to influence healthcare quality standards while leading a dedicated team committed to delivering exceptional patient care through efficient utilization management. If you are passionate about healthcare management with a focus on clinical excellence and regulatory compliance—apply now to make a meaningful impact!

Pay: $60,000.00 - $70,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person