Mgr-RN, Utilization Management

It's more than a career, it's a calling.

MO-REMOTE

Worker Type:

Regular

Job Summary:

Oversees the system wide day-to-day operational management of Utilization Management (UM) activities and services and the development of a high performing team. Analyzes the effectiveness of programs and staff. Exercises discretion and independent judgment that directly supports UM activities.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Responsible for department operations, which includes referrals, medical necessity and experimental/investigational reviews, and application of medical policies and business processes.
• Ensures the quality and accuracy of Utilization Management (UM) review decisions, and the adherence to UM and Care Management departmental policies.
• Participates in the development of policies and oversee staff activities to ensure compliance with regulatory and accrediting standards.
• Oversees staffing and productivity and adjusts staffing patterns to provide adequate coverage for UM operations during absences and vacancies.
• Monitors and adheres to budget. Approves or monitors expenditures, purchases, and other actions to ensure compliance with budget guidelines.
• Ensures that the UM team meets performance metrics and work plan requirements.
• Represents UM in the participation on committees, task forces, work groups and multidisciplinary teams, as assigned.
• Assists with the development, maintenance, and adherence of UM programs and processes.
• Assists and participates in meeting company and department goals such as quality improvement activities.
• Recruits, engages, develops, leads, and manages assigned staff.
• Performs other duties as assigned.

EDUCATION

• Bachelor's degree in nursing

EXPERIENCE

• Two years' registered nurse experience and three years' utilization management experience, with two years' of demonstrated progressive leadership experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois 

•     Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) 

     
State of Work Location: Missouri 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Missouri Division of Professional Registration 

 
State of Work Location: Oklahoma 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Regi