Manager Nurse Utilization

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Under the direction of the Director of Professional Staff Services, the Utilization Manager acts as a liaison to hospital leadership, Case Management, Compliance, Revenue Cycle Departments, and Finance. This position is part of an interdisciplinary team that reviews and determines the appropriateness of hospital admissions and medical necessity for continued stay, ensuring medical documentation accurately reflects patient care in collaboration with bed control, case management, coding, and billing. The Utilization Nurse Manager monitors Medicare and State regulations for upcoming criteria, gathers and disseminates information for regulatory analysis, and may develop and implement action plans as needed.

Essential Functions

• Participates in professional growth through publications, seminars, workshops, conferences, and affiliations.
• Acts as an educational resource on utilization issues, prepares presentation materials, and reports.
• Maintains knowledge of clinical practices, technology changes, and regulatory issues.
• Collaborates on audits, regulatory deliverables, and implements corrective actions and staff training.
• Creates and analyzes reports to identify utilization concerns using various applications.
• Maintains records, databases, and tracks actions and outcomes.
• Implements new processes based on trend analysis and needs.
• Assists with reviews, denials management, utilization monitoring, and compliance requirements.
• Develops and maintains policies and procedures for regulatory agencies.

Minimum Qualifications

Knowledge, Skills, and Abilities

Additional Details

This job posting is active and not expired.

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