Manager, Utilization Management

Our take on this role

About this role

Oversee healthcare service review and authorization, and lead a utilization management team. Manage resource use and implement policies and procedures to meet regulatory requirements and industry standards.

What could you bring from clinical work?

• Nurses: Your experience assessing care needs and documenting medical necessity may help when overseeing healthcare service review and authorization.
• OTs and PTs: Evaluating functional needs and documenting rehabilitation medical necessity could help you review and authorize medical services using established guidelines.
• Social workers: Assessing behavioral health needs and levels of care could help you review whether medical services are necessary and appropriate.
• SLPs: Documenting medical necessity for communication and swallowing services may help you review medical services using established utilization management guidelines.

Full job description from Independent Living Systems, LLC

We are seeking a Manager, Utilization Management to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Manager, Utilization Management plays a vital role in overseeing the evaluation and authorization of healthcare services to ensure appropriate, cost-effective care delivery. This position is responsible for overseeing the utilization management process to ensure efficient and effective use of resources. The Manager, Utilization Management is also responsible for developing and implementing utilization management policies and procedures to ensure compliance with regulatory requirements and industry standards. The Manager, Utilization Management will lead a team of utilization management personnel to review and authorize medical services, ensuring that they are medically necessary and appropriate. The Manager, Utilization Management’s role is vital in ensuring that patients receive the highest quality of care while managing costs for the organization.

Minimum Qualifications:

• Bachelor's degree in nursing, healthcare administration, or related field
• 3 years of experience in utilization management or related field
• Experience leading a team of utilization management professionals
• Strong knowledge of regulatory requirements and industry standards
• Relevant experience may substitute for the educational requirement on a year-for-year basis

Preferred Qualifications:

• Master's degree in nursing, healthcare administration, or related field
• Experience working in a managed care organization
• Certification in utilization management or related field

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Lead and manage a team of utilization management personnel to review and authorize medical services, ensuring that they are medically necessary and appropriate.
• Manage utilization management processes to ensure efficient and effective use of resources.
• Utilize established utilization management guidelines to review and authorize medical services.
• Ensure that medical services are medically necessary and appropriate.
• Implement utilization management activities in accordance with established policies and procedures.
• Ensure compliance with regulatory requirements and industry standards.
• Perform other duties as assigned.