Manager, Utilization Review (RN)

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Work Shift

Day

Work Day(s)

Friday, Monday, Thursday, Tuesday, Wednesday

Shift Start Time

8:00 AM

5:00 PM

Regular

Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s.

Provides leadership and oversight of the Utilization Review department, ensuring appropriate utilization of healthcare resources. Effectively manages all utilization review functions, including clinical reviews, concurrent authorization and denials management, status changes, and identification and escalation of payer trends. Partners with a broad range of stakeholders, including case management, social work, patient access, clinical operations, physicians, managed care, and IS&T. Establishes and manages productivity, quality, and other key performance indicators, providing feedback to staff related to performance regularly. Produces reporting and performs analysis of data relevant to utilization review functions.

Experience

• 5 years of RN experience in emergency, intensive care, and/or medical-surgical acute care settings
• 2 years of experience in a supervisory or management role

Preferred Qualifications

• Master's degree in nursing, business, or other healthcare related field
• Utilization review experience
• Previous experience with InterQual and/or MCG
• Epic experience
• MS Word, Excel expertise

Education

• Bachelor of Science in Nursing

Certification Summary

• Licensure as a Registered Nurse in the single State of Georgia or multi-state through the Enhanced Nurse Licensure Compact

Knowledge, Skills, and Abilities

• Excellent communication skills, both verbal and written
• Demonstrated critical thinking, problem-solving and decision-making skills
• Demonstrated knowledge of hospital utilization review and revenue cycle operations
• Demonstrated clinical expertise and proven ability to effectively and efficiently perform chart reviews  
• Proficiency in Microsoft Excel, Word, and PowerPoint

Job Responsibilities

• Oversees management and operations of the Utilization Review department, including developing, directing, and managing all members of the team.
• Functions as a subject matter expert for staff and other stakeholders, demonstrating a thorough knowledge of all utilization review processes, policies and procedures.
• Develops, maintains, and communicates utilization review policies and procedures and ensures compliance with organizational, state and federal regulations.
• Recruits, hires, orients, and continuously trains new employees to ensure success and a thorough understanding of necessary policies, processes, and procedures.
• Develops staff and departmental performance expectations, metrics, and goals and holds self and staff accountable.
• Establishes and communicates performance and behavioral standards and follows appropriate disciplinary courses of action when counseling staff.
• Uses data to monitor and analyze performance against standards and goals, identify trends, and make adjustments as necessary.
• Collaborates with a broad range of stakeholders, including case management, social work, patient access, clinical operations, physicians, managed care, and IS&T.
• Communicates with and educates physicians and other clinical staff as needed regarding utilization review policies, practices, and procedures.
• Mentors team members to encourage personal and professional growth.
• Encourages ongoing skill development by providing opportunities for continued education.
• Performs other duties as necessary or assigned.

Children’s Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law.

1575 Northeast Expy NE

Nursing-Management