Employment Type:

Full time

Shift:

Day Shift

Description:

Position Summary and Highlights:

Saint Alphonsus is hiring a Utilization Review Manager to lead the Utilization Review Team in Boise, Idaho.

This role oversees daily utilization review operations, serving as the first point of escalation for problem-solving and ensuring compliance with payer and regulatory requirements. It provides supervisory leadership, including scheduling, coaching, performance management, and supporting staff development. The position is responsible for readmission prevention programs, denial management workflows, and securing insurance authorizations through clinical reviews and active payer communication. It also collaborates closely with Physician Advisors and leadership to optimize processes, maintain data reporting, and support organizational goals. Strong communication, regulatory knowledge, and the ability to work independently are essential for success in this role.

Why Join Saint Alphonsus?

• Award-Winning Culture - Saint Alphonsus Health System is recognized as one of America's Best Large Employers by Forbes.
• Day 1 Benefits – colleagues are eligible for our plans from their very first day of work.

Minimum Qualifications:

• Licensed in the State of Idaho as a Registered Nurse as defined by the Idaho State Board of Nursing.
• BSN required
• 5 or more years of experience in case management required. 7 or more years preferred.
• 2 or more years of supervisory experience required.
• American Heart Association Basic Life Support for HealthCare Provider (BLS/HCP) certification required

What You Will Do:

• Performs coaching/feedback, completes timely evaluations, and resolves staff conflict.
• Excellent communication skills and ability to form working relationships with third party payors and physicians.
• Lead all cause readmission prevention programs
• Maintains appropriate staffing/scheduling to support utilization management process and functions.
• Maintains accurate and up-to-date employee files consistent with organizational policies/practices.
• Help ensure organizational commitment to patient satisfaction. Reacts in a timely manner to resolve patient complaints and promotes customer service standards among staff.
• Help ensure effective cost/expense management.
• Excellent organization and documentation skills.
• Assists Manager with staff meetings on a regular basis.
• Attends and participates in off-site meetings and/or seminars.
• Ensures compliance with policies and procedures (organizational, insurance, etc.). Helps ensure compliance with OSHA, CLIA, and State radiological safety standards as well as any other local, state, or federal mandates.
• Demonstrates ability to work independently and take initiative.
• Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, and Geriatric as applicable).
• Research all possible payors by contacting the Insurance Verification Dept. and other resources to verify patients’ eligibility.
• Assists the Manager in hiring, training, coaching, and evaluating personnel and directs the clinical supervision of the team either through individual or group supervision or through formal case consultations.
• When necessary, conduct in-person assessment interview with potential and new patients and /or their families to determine financial resources and insurance coverage.
• Reviews necessary medical records, relaying clinical information to payors and documenting authorization.
• Obtains authorization from insurance companies, documents result and notifies appropriate staff.
• Interacts with health care providers to identify medical necessities and appropriateness of admission to the inpatient setting and provides feedback to staff on appropriate documentation to support the need for admission.
• Responds to patient and patient's family by answering their questions regarding the patient's ongoing benefits during his/her inpatient treatment.
• Assists Assessment and Referral Department in determining coverage issues that may affect patient's decisions to voluntarily admit to this facility.
• Maintains a strong relationship with insurance payers to facilitate discussions regarding authorization approvals.
• Assists in obtaining insurance authorization when clinical information is required.
• Serve as a liaison between the hospital and external payers on issues related to severity of illness and intensity of service for patien