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Utilization Review Manager
Ensemble Health Partners. Lead and manage the centralized Virtual Utilization Management Program .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in leading Virtual Utilization Management Programs, ensuring compliance with insurance regulations, and managing clinical operations to enhance patient care and departmental efficiency. Proficient in utilizing MCG guidelines and advanced AI tools to drive program improvements and staff development.
Highest-signal resume keywords
MCG CertificationUtilization ManagementClinical DocumentationInsurance RegulationsTeam Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Nursing DegreeMCG GuidelinesDatabase AnalysisSpreadsheet AnalysisProgram ComplianceOperational EffectivenessBudget ManagementProcess RedesignDenial ManagementAppeal Management
Soft Skills
Effective CommunicationNegotiation SkillsLeadershipStaff DevelopmentCollaboration
Tools & Technologies
AI ToolsUtilization Management SoftwareDatabase SystemsSpreadsheet Software
Certifications & Qualifications
MCG CertificationNursing License
Industry Keywords
Utilization ManagementMedicare GuidelinesMedicaid GuidelinesClinical OperationsCare Coordination
About the role
Key responsibilities & impact- Lead and manage the centralized Virtual Utilization Management Program
- Maintain departmental support structures for clinical and operational excellence
- Oversee authorization, denials, and appeals for inpatient, observation, and outpatient services
- Manage system program compliance, development, and strategy
- Collaborate with authorization managers, hospital-based utilization management leaders, physician advisors, Coding, Care Coordination, Clinical Documentation Specialists, and Health Information Management
- Develop and manage Medical Management department activities to meet corporate targets and goals
- Develop an annual utilization management work plan and report completed activities
- Oversee operational activities of Virtual Utilization Management staff
- Support Care Coordination to improve length of stay and excess days
- Support Clinical Documentation department operational effectiveness
- Participate on committees and conduct studies to improve denial and appeal processes
- Lead process redesign to eliminate excess days and decrease inpatient length of stay
- Track and trend program compliance
- Monitor and evaluate utilization management staffing productivity and effectiveness
- Manage denial and appeal staff to reduce inpatient/observation denials and improve appeal outcomes
- Collaborate with facility-based Care Coordination staff to maximize appropriate level of care and decrease length of stay
- Review department programs for compliance with state and regulatory guidelines
- Identify staff development opportunities and evaluation tasks
- Own annual employee engagement efforts and action plans for utilization management staff
- Develop and manage departmental budgets and goals
- Review monthly budget reports and create action plans for variances
- Perform other duties as assigned
Requirements
What you’ll need- 2 Year/Associates Degree in Nursing required
- Current unrestricted license to practice nursing in the resident State
- MCG Certification required within 6 months of hire
- Broad knowledge and skilled use of MCG or nursing criteria guidelines
- Broad knowledge of insurance regulations and Medicare and Medicaid guidelines
- Proficient computer usage, especially database and spreadsheet analysis
- Proficient in communicating clearly and effectively with multiple constituents
- Skills required to run a fiscally responsible program while ensuring constant improvement
- Proficient in negotiating complex systems to effect positive change
- Demonstrated advanced usage of AI and management of teams using AI
- Must reside in and be authorized to work within the United States
- Must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require
Benefits
Comp & perks- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive benefits package including healthcare, time off, retirement, and well-being programs
- Professional development and relevant professional certification for each associate
- Quarterly and annual incentive programs
- Career advancement opportunities
- Remote work flexibility