Utilization Review Manager | RN - Bachelors Degree Required | Hospital System | Alabama

Competitive Compensation | Comprehensive Benefits | Outstanding Support System | Relocation Assistance | Leadership Advancement Opportunities

Nestled in the heart of the South, recognized among the ‘Top 25 US Places for Affordable Cost of Living,’ this vibrant city boasts a tapestry of historical landmarks, dynamic performing arts venues, lively sporting events, premier shopping destinations, and a melting pot of culinary delights, catering to every palate. Whether you're exploring its rich history or indulging in its diverse food scene, there's never a dull moment for residents.

Beyond its cultural offerings, the city and surrounding areas are known for reasonable housing prices, below-average national taxes, and an overall economic lifestyle, making it an ideal locale for enhancing your standard of living.

Moreover, the region enjoys a delightful climate year-round, boasting vibrant autumns, rejuvenating springs, inviting summers, and mild winters. Its proximity to beachfront and mountainous landscapes offers residents unparalleled opportunities for outdoor recreation and adventures. Snow and ice are a rarity, and even in the coldest months, the average low temperatures remain comfortably above freezing, ensuring year-round enjoyment of the great outdoors.

Alabama

• Reports to the Assistant Vice President (AVP) of Case Management
• Oversee daily operations related to utilization review and appeals management across assigned facilities
• Supervise a team of Utilization Review and Appeal Management Specialists (16 RN FTEs)
• Develop, implement, and continuously improve policies and operational procedures to streamline utilization review and appeal management processes
• Provide guidance, training, and support to staff, ensuring high standards of performance and adherence to protocols
• Work closely with physicians, nursing staff, and other healthcare professionals to coordinate patient care, ensuring efficient use of resources while maintaining quality care standards
• Facilitate efficient utilization of hospital resources to optimize both clinical and financial outcomes
• Implement strategies to reduce unnecessary costs while ensuring high-quality patient care
• Identify areas for improvement within the utilization review process and develop initiatives to enhance patient care delivery, staff efficiency, and compliance with healthcare regulations
• Collaborate with insurance carriers and healthcare providers to support reimbursement decisions and maintain accurate documentation of patient care plans
• Conduct regular audits of patient treatment files to ensure compliance and prevent unnecessary procedures or hospital stays

• Bachelor’s Degree required
• Active RN License required
• Change Healthcare InterQual Certified Expert Resource Certification or acquired within one year
• Certified Case Manager (CCM) certification preferred
• Minimum of 5 years of hospital-based experience in concurrent utilization review and appeals management
• Experience with third-party payor requirements
• In-depth knowledge of Joint Commission and CMS Conditions of Participation
• Proficient in using electronic health records and other healthcare software systems
• Strong analytical and critical thinking skills to assess medical necessity and optimize patient care
• Ability to establish and maintain effective working relationships with all levels of hospital staff

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