RN Manager, Utilization Review Full time Days

Be a part of a world-class academic healthcare system Company as a RN Managerin the Rev Cycle Department. This position will be primarily a work from home opportunity with the requirement to come onsite as needed. You may be based outside of the greater Chicagoland area.

The Manager of Utilization Review (UR) provides leadership and oversight of utilization review activities across the health system including the academic medical center and affiliated community hospitals. This position ensures consistent application of medical necessity criteria compliance with payer and regulatory requirements and alignment of utilization management (UM) practices across all entities. The Manager serves as the primary liaison between the health system external utilization review vendors and internal stakeholders including physicians case management and revenue cycle teams. The role focuses on optimizing patient status determinations reducing avoidable denials and supporting appropriate reimbursement through collaboration education and data-driven oversight.

Essential Job Functions

• Oversee daily utilization review operations across multiple hospital sites to ensure timely compliant reviews and consistent application of UM standards.
• Develop implement and monitor system-wide UR policies workflows and performance metrics.
• Identify opportunities and maintain responsibility for technology optimization including EMR workflows and other UR platforms.
• Supervise and mentor UR staff and coordinate work between onsite and centralized review teams as applicable.
• Serve as a subject matter expert on medical necessity payer requirements and regulatory standards (CMS Joint Commission state). Maintain oversight of interdisciplinary education to ensure consistent understanding of UM
• criteria across departments (case management physician advisors financial counselors etc.)
• Act as the primary point of contact for the systems external Utilization Review vendor ensuring high-quality timely reviews and compliance with contractual performance metrics.
• Monitor vendor performance dashboards review audit findings and lead performance improvement initiatives. Provide input to contract negotiations.
• Collaborate with external partners to streamline communication resolve escalations and enhance consistency across hospital sites.
• Track and analyze utilization metrics denial trends and audit outcomes across the system.
• Prepare regular reports for leadership highlighting performance compliance and financial impact. Benchmark against national standards and peer institutions and create action plans to meet those standards.
• Identify opportunities for improvement in review processes technology use and documentation practices.
• Provide root cause analysis of denials and missed reviews as applicable.
• Participate in and/or coordinate daily multidisciplinary rounds with clinical and case management teams to support real-time status determinations and discharge planning.
• Serve as a liaison between hospitalists attending physicians physician advisors CDI and UR staff to ensure appropriate documentation of medical necessity and level of care.
• Build strong working relationships with Revenue Cycle Case Management CDI and Physician Leadership teams to ensure alignment of clinical and financial objectives.
• Partner with Denials CDI Payer compliance and Revenue Integrity teams to address payer trends and support denial prevention strategies.
• Provide education and support to clinical staff and physicians on UM criteria (InterQual MCG) medical necessity documentation and payer requirements.
• Stay current with regulatory updates payer policies and value-based care trends impacting utilization management.
• Participate in policy and training development for payer trends applicable to the UR function.
• Ensure all UR activities comply with CMS Conditions of Participation and other regulatory standards and monitor competency assessments of UR staff.

RequiredQualifications

• Minimum 5 years of clinical experience in an acute care setting.
• Minimum 35 years of experience in Utilization Review Case Management or Denials Management preferably in a health system or multi-site environment.
• Demonstrated experience in vendor management and cross-functional collaboration.
• Prior supervisory or leadership experience : Current Registered Nurse (RN) license in good standing.
• Required: Bachelors degree in Nursing (BSN).
• Preferred: Masters degree in Nursing Healthcare Administration or related field.

Position Details

• Job Type: Full Time (1.0FTE)
• Shift: Days
• Work Location: Full Time (Hybrid) Hyde park Crown Point and Ingalls rotation.
• Unit/Department: Revenue Cycle
• CBA Code:Non-Union

Weve been at the forefront of medicine since 1899. We provide superior healthcare with compassion always mindful that each patient is a person an individual. To accomplish this we need employees with passion talent and commitment with patients and with each other. Were in this together: working to advance medical innovation serve the health needs of the community and move our collective knowledge forward. If youd like to add enriching human life to your profile UChicago Medicine is for you. Here at the forefront were doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at:UChicago Medicine Career Opportunities

UChicago Medicine is an equal opportunity employer. We evaluate qualified applicants without regard to race color ethnicity ancestry sex sexual orientation gender identity marital status civil union status parental status religion national origin age disability veteran status and other legally protected characteristics.

As a condition of employment all employees are required to complete a pre-employment physical background check drug screening and comply with the flu vaccination requirements prior to hire. Medical and religious exemptions will be considered for flu vaccination consistent with applicable law.

Compensation & Benefits Overview

UChicago Medicine is committed to transparency in compensation and benefits. The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position.

The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union.

Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.