Manager Utilization Review - Care Coordination Admin - Full Time 8 Hour Days Exempt Non-Union

The Manager of Utilization Review provides administrative and operational support to the Director of Case Management. The Manager of Utilization Review provides direct supervision to the Utilization Review Specialists Utilization Management Specialists Authorization Coordinators and ancillary staff. The Manager provides staff support regarding difficult/complex cases. The Manager is accountable for daily department operations including establishing utilization review processes that conform to evidencebased review expectations payer expectations support collaboration with organizations billing partners and appeal processes. This position is responsible for daily team operations including staffing assignments and human resources management.

Essential Duties:

• Leadership & Supervision: Manage and mentor a team of RN Utilization Review Specialists LVN Utilization Management Specialists Authorization Coordinators and ancillary staff. Provide guidance and support in the development of staff skills and competencies including but not limited to orienting training daily staffing and staff assignments. Conduct performance evaluations and implement development plans for team members. Engage in special projects research consultation and teaching in areas of specialty as needed by the hospital. Provide leadership in quality management and improvement activities by planning organizing coordinating monitoring and evaluating care and activities provided by personnel.
• Clinical Review Oversight: Supervise the clinical review process to ensure reviews are conducted accurately and in line with evidencebased guidelines.
• Develop and implement standards and processes for clinical and nonclinical services provided by Utilization Review team members including provides organizational planning and program development for needed services. Utilizes advanced theoretical knowledge and skills to act as consultant to the staff and to the administrative team. Collaborate with clinical teams within Care Coordination to resolve complex cases and ensure authorizations of appropriate care levels. Formulates and implements policies and procedures related to areas of management and provides feedback and statistics to hospital administration regarding areas of oversight. Maintains competencies for hospital age specific and job specific standards of care follows hospital procedures for accurate and timely processing of charges.
• Appeals Management: Develop and implements standards and processes for the formulation and submission of appeal requests for denied services ensuring they are complete accurate and submitted in a timely manner. Analyze trends in denied claims and collaborate with internal and external partners to address and rectify identified issues.
• Regulatory Compliance: Ensure that all processes comply with relevant healthcare regulations accreditation standards and organizational policies. Stay updated on industry standards and changes in regulations to maintain compliance. Legal and ethical standards to be incorporated into all aspect of Utilization Review processes.
• Process Improvement: Identify and implement process improvements to enhance the efficiency effectiveness and outcomes of the Utilization Review team. Develop and maintain departmental policies and procedures. Participate in the development monitoring and analysis of process and outcome indicators for the improvement of patient care.
• Reporting and Analytics: Generate and analyze reports related to utilization review activities and appeal outcomes. Use data to drive decisionmaking and to identify opportunities for improvement. Prepare and present reports reflective of utilization review activities and appeal outcomes to department meetings UM Committee meetings and other committee meetings upon request.
• Performs other duties as assigned.

Required Qualifications:

• Req Bachelors Degree Nursing

• Req 35 years Clinical experience with an additional five years of experience in hospitalbased utilization review.
• Req 2 years Consecutive years experience in Utilization Review leadership in a manager or above capacity.

• Req Strong leadership and team management skills.
• Req Indepth knowledge of clinical review and appeal processes and healthcare regulations.
• Req Excellent analytical problemsolving and decisionmaking abilities.
• Req Ability to work independently with minimal supervision exercising judgment and initiative.
• Req Ability to perform a variety of complex and administrative duties and manage conceptual assignments.
• Req Effective communication and interpersonal skills.
• Req Demonstrates ability to effectively work with physicians staff and patients.
• Req Committed to excellence in patient care and customer service.

Preferred Qualifications:

• Pref Certified Case Manager CCM (CMSA) Nationally recognized certification such as CCM and/or ACM
• Pref Proficiency in utilizing healthcare management software and data analysis tools.

Required Licenses/Certifications:

• Req Registered Nurse RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association

Req Fire Life Safety Training (LA City) If no card upon hire one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin protected veteran status disability or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance and with due consideration for patient and student safety. Please refer to theBackground Screening Policy Appendix Dfor specific employment screen implications for the position for which you are applying.

We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone ator by email at. Inquiries will be treated as confidential to the extent permitted by law.

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