Description
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.
Location:
Opportunity:
- 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
Qualifications:
- 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
About Galileo Search:
Galileo Search, LLC partners with hospitals and healthcare organizations across the United States to identify, recruit, and retain the industry's most accomplished professionals and executives. Our clients include community and critical access hospitals, health systems, academic medical centers, and Fortune 500 corporations. To learn more about Galileo Search, LLC, visit our website at www.galileosearch.com
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Job ID:
Job-029433