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Manager, Utilization Management

Description:

The Manager of Utilization Management plays a pivotal role in ensuring that hospital resources are used efficiently, appropriately, and in alignment with clinical best practices. This position leads the development and execution of utilization review strategies that support timely, medically necessary care while minimizing unnecessary costs and delays. By collaborating with physicians, case managers, and administrative teams, the Manager ensures compliance with regulatory requirements, payer guidelines, and internal quality standards. Through data analysis, process improvement, and staff leadership, this role drives optimal patient outcomes, enhances operational performance, and supports the hospitals mission to deliver high-value care across the continuum.

RESPONSIBLE FOR:
System level matrix over site of the utilization management activities

Qualifications:

MINIMUM EDUCATION REQUIRED:
Graduation from a School of Nursing

MINIMUM EXPERIENCE REQUIRED:
At least 5 years of experience with acute hospital utilization management and review processes, using medical necessity criteria (InterQual and/or Milliman). At least 2 years of management experience of professional staff.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Current Georgia RN licensure

ADDITIONAL QUALIFICATIONS:
IQCI certification required. Detailed knowledgeable of federal and state hospital Utilization Review (UR) regulations, Medicare Conditions of Participation, Medicare Guidelines regarding medical necessity, hospital admissions processes, level of care determination, hospital services and hospital continued stays. Expert knowledge of Interqual criteria. Ability to verbally and in writing communicate with many different departments and physicians including but not limited to: Admissions Department, Patient Financial Services, Compliance, Medical Records, Physician Advisors, UR front line staff and Physician Leadership.