Utilization Review Manager

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Utilization Review Manager based in United States. This is a strategic clinical leadership role overseeing a centralized Virtual Utilization Management program in a complex healthcare environment. You will lead teams responsible for utilization review, authorizations, denials, and appeals across inpatient, observation, and outpatient services. The role combines clinical expertise with operational leadership, regulatory compliance, financial accountability, and continuous process improvement. You will collaborate with hospital-based leaders, physicians, care coordination, clinical documentation, coding, and revenue cycle teams to improve outcomes and reduce unnecessary costs. A key focus will be optimizing length of stay, strengthening denial and appeal performance, and maintaining high standards of program compliance. This remote opportunity is ideal for an experienced nursing and utilization management leader who is comfortable driving change, developing teams, and leveraging technology and AI to improve healthcare operations. Accountabilities - Lead and manage the centralized Virtual Utilization Management program, ensuring clinical and operational excellence across utilization review activities. - Oversee utilization management processes covering inpatient and observation/outpatient authorization, denials, and appeals. - Develop annual utilization management work plans aligned with strategic priorities and departmental goals, and report progress to senior leadership. - Provide operational leadership and resources to virtual utilization management teams while supporting Care Coordination and Clinical Documentation functions. - Partner with hospital-based utilization management leaders, physician advisors, physicians, nurse practitioners, physician assistants, Care Coordination, Coding, Clinical Documentation, Health Information Management, and Revenue teams.

- Develop and implement strategies to reduce inappropriate denials, improve appeal outcomes, address failed billing issues, and optimize reimbursement. - Drive initiatives to reduce excess inpatient days and improve overall length of stay through effective utilization management and interdisciplinary collaboration. - Monitor staffing productivity, team effectiveness, program performance, and compliance, taking corrective action when needed. - Ensure utilization management practices comply with applicable state regulations, Medicare and Medicaid requirements, insurance regulations, and organizational policies. - Apply MCG or comparable clinical criteria appropriately when evaluating medical necessity and utilization decisions. - Identify process redesign opportunities that improve efficiency, eliminate unnecessary work, and strengthen clinical and financial outcomes. - Lead studies, committees, and improvement initiatives designed to demonstrate measurable progress in denial, appeal, utilization, and patient-flow outcomes. - Identify employee development opportunities, support performance management, and maintain an active engagement and development plan for utilization management staff. - Manage departmental budgets in partnership with senior utilization management leadership, including staffing requirements, resource planning, and future growth needs. - Review monthly budget and operational reports, identify variances, and develop action plans to maintain financial and performance targets. - Explore and apply AI-enabled technologies and process improvements to increase operational efficiency and support better utilization management outcomes. - Travel to client, temporary, or corporate locations when business requirements call for onsite support. Requirements - Associate degree in Nursing is required; a Bachelor’s degree in Nursing is preferred.