**Job Summary** The Manager of Utilization Review oversees a team of utilization review nurses and coordinators, ensuring compliance with clinical regulatory standards, and enhancing the overall utilization review process to optimize patient care and manage resources effectively. The manager supports and coordinates the various aspects of the hospital's utilization management program, denials and appeals activities. Works with UR Director, UR Senior Director, and Payor Relations Manager to facilitate coordination of services related to utilization review. Collaborates with the multidisciplinary team, lending professional clinical expertise to ensure quality, timely, and cost effective utilization management to achieve optimal outcomes. The manager will be responsible for implementing process improvement plans and projects to maximize desired outcomes. **Essential Functions** + Serves as escalation point and oversight of daily functions for UR Clinical Specialists and Coordinators for questions or concerns regarding appropriateness and medical necessity of admission and continued hospital stay. + Coordinates with Regional Case Management Directors to address identified issues and trends or escalated challenges. Communicates Utilization Review information with facility Case Manager Directors, proactively sharing KPI (Key Performance indicator) data and trends with facility leadership. + Collaborates with the UR Senior Director, Director and Payor Relations Manager to support dashboard/reporting, solution, and training needs based on trends and common issues. + Efficiently refers cases to the Physician Advisor or representative of the UR committee when cases are not meeting criteria. + Distinctively establishes and maintains criteria or identifies resolutions of problems associated with Utilization Review functions for committee. + Completes employee evaluations in a timely manner and assesses staff competencies on an ongoing basis. Collaborates with Training & EducationSpecialist(s) and Coordinators to address educational needs for staff. + Tasked with problem analysis and resolution as it pertains to the areas of job responsibility. + Maintains performance metrics in line with Utilization Review Service Line KPIs. + May serve as a key contact for facility and insurance contacts. + Ensures staff compliance with regulatory requirements including but not limited to Condition Code 44, 2 midnight IP cert audits, physician orders for correct status level, etc. + Ensures the operation of the Utilization Review department in their area is in compliance with established UR policies, procedures and guidance documents. + Performs responsibilities that contribute towards meeting or exceeding team goals. + Promptly escalate appropriate issues to Director and/or Senior Director. + Provide suggestions and/or recommendations for changes to applicable processes or tools as recognized from functioning in the role on a daily basis. + Provide oversight of department staff to ensure adherence to above duties. + Performs other duties as assigned. + Complies with all policies and standards. **Qualifications** + Associates or Bachelor’s Degree in Nursing required + Bachelor’s or Master’s Degree in Nursing preferred + 3-5 years work experience in healthcare as a nurse required + 1-3 years work experience in Care Management or Utilization Review required + 1-2 years work experience as a healthcare manager preferred **Knowledge, Skills and Abilities** + Strong analytical skills for reviewing medical records and treatment plans. + In-depth knowledge of healthcare policies and regulations. + Strong communication, organizational and customer service skills required. + Proven ability to work successfully in a fast-paced environment while maintaining good relationships with co-workers and supervisors. + Demonstrated proficiency in computer and web-based applications. **Licenses and Certifications** + CN-RN - General Nursing Practice RN license required + Active compact state license or active license in the states of support and review required Equal Employment Opportunity This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.