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Utilization Manager II
Sharp HealthCare. Support utilization review functions from pre-admission through discharge and final status reconciliation .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization management and case management within a hospital or payer setting, ensuring compliance with regulations and effective collaboration with interdisciplinary teams. Proficient in maintaining accurate documentation and utilizing information systems to support patient care and departmental excellence.
Highest-signal resume keywords
Utilization ManagementAcute Care Nursing ExperienceCalifornia Registered Nurse (RN) LicenseEvidence-Based GuidelinesAccredited Case Manager (ACM) Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewClinical SkillsDocumentation AccuracyData AnalysisPatient Coordination
Soft Skills
CollaborationFlexibilityMentoringPrioritizationCommunication
Tools & Technologies
WordExcelInformation Systems
Certifications & Qualifications
Accredited Case Manager (ACM)Certified Case Manager (CCM)
Industry Keywords
HealthcareRegulations ComplianceInterdisciplinary Care TeamsMilliman Care Guidelines (MCG)Utilization Management Regulations
About the role
Key responsibilities & impact- Support utilization review functions from pre-admission through discharge and final status reconciliation
- Ensure timely interaction with admitting and attending physicians, payers, physician advisors, and interdisciplinary care teams
- Coordinate utilization management activities with Revenue Cycle
- Ensure compliance with local, state, and federal utilization review and care management regulations
- Perform initial and concurrent reviews for intent-to-bed and bedded patients
- Identify and escalate cases that do not meet admission or continued-stay criteria
- Advise physician advisors and help mitigate denials
- Review hospitalized patients with Physician Advisors or facility UR chairpersons
- Identify and report emerging variances and trends
- Maintain utilization records and statistics, including bed days, discharges, readmissions, and diagnoses
- Complete documentation accurately and on time
- Coordinate transfers of out-of-network patients when indicated
- Maintain confidentiality of patient and utilization management information
- Participate in ICM care conferences and utilization review projects
- Maintain logs and reports for high-risk, long-stay, and outlier patients
- Facilitate information sharing and project coordination across teams and facilities
- Develop collaborative relationships with nursing departments, payers, hospitals, physicians, and medical groups
- Mentor new hires and orientees under the direction of ICM Centralized UM leadership
- Drive departmental excellence, process improvement, and team performance
- Participate in professional development and identify performance improvement opportunities
Requirements
What you’ll need- Bachelor's Degree in Healthcare or a related field
- 3 years of utilization management or case management within a hospital or payer setting
- 3 years of acute care nursing experience
- 2 years of recent pertinent clinical experience as defined by the CBA
- California Registered Nurse (RN) license required
- Proficiency with information systems and computer programs such as Word and Excel
- Advanced clinical skills in area of expertise
- Proficient knowledge and understanding of utilization management
- Demonstrated understanding and competency with evidence-based guidelines
- Ability to prioritize and work independently
- Ability to remain flexible in a rapidly changing environment
- Ability to work collaboratively with an interdisciplinary team
- Preferred: Bachelor's Degree in Nursing
- Preferred: Experience with Milliman Care Guidelines (MCG)
- Preferred: Experience and understanding of federal and state regulations governing utilization management
- Preferred: Accredited Case Manager (ACM) certification
- Preferred: Certified Case Manager (CCM) certification
Benefits
Comp & perks- Hybrid schedule: 3/2 or 5/5 after satisfactory training is completed
- No on-call required
- Weekend requirements: As needed