Utilization Review

Manager of RN Utilization ManagementIt's more than a career, it's a callingMO-REMOTEWorker Type: RegularJob Highlights:Lead a team dedicated to delivering high-quality, cost-effective patient care. As the Manager of RN Utilization Management, you'll combine clinical expertise with strategic leadership to oversee care coordination, utilization review, and regulatory compliance initiatives, helping ensure patients receive the right care at the right time while driving exceptional outcomes across the continuum of care.Scheduling & Logistics:The position is fully remote.Candidates must reside in our footprint state, MO OK, IL or WI.Preference is given to candidates located in the St. Louis region due to the Mission Hill Corporate office location.Standard work hours are Monday through Friday, 8:00 a.m. to 4:30 p.m.Occasional weekend support may be required, as the role includes managing weekend staff. This support is ad hoc and not a formal on-call requirement.Skills & Matching Criteria:Extensive Utilization Management experience or Case Management experience.Strong understanding of CMS, Medicare & Medicaid, and Commercial regulations.Experience leading large cross-functional teams at a management level.Experience leading denials and appeals resolutions.Experience analyzing denial, authorization, and utilization data to identify trends, opportunities, and areas for improvement.Ability to embrace change and promote continuous improvement.Effective leadership through evolving priorities and organizational initiatives.Ability to foster a culture of accountability, collaboration, adaptability, and engagement.Ability to serve as a trusted partner to staff, physicians, and operational leaders.Job Summary:Oversees the system wide day-to-day operational management of Utilization Management (UM) activities and services and the development of a high performing team. Analyzes the effectiveness of programs and staff. Exercises discretion and independent judgment that directly supports UM activities.Job Responsibilities and Requirements:PRIMARY RESPONSIBILITIESResponsible for department operations, which includes referrals, medical necessity and experimental/investigational reviews, and application of medical policies and business processes.Ensures the quality and accuracy of Utilization Management (UM) review decisions, and the adherence to UM and Care Management departmental policies.Participates in the development of policies and oversee staff activities to ensure compliance with regulatory and accrediting standards.Oversees staffing and productivity and adjusts staffing patterns to provide adequate coverage for UM operations during absences and vacancies.Monitors and adheres to budget. Approves or monitors expenditures, purchases, and other actions to ensure compliance with budget guidelines.Ensures that the UM team meets performance metrics and work plan requirements.Represents UM in the participation on committees, task forces, work groups and multidisciplinary teams, as assigned.Assists with the development, maintenance, and adherence of UM programs and processes.Assists and participates in meeting company and department goals such as quality improvement activities.Recruits, engages, develops, leads, and manages assigned staff.Performs other duties as assigned.EDUCATIONBachelor's degree in nursingEXPERIENCETwo years' acute nursing registered nurse experience and five years' utilization management experience, with two years' of demonstrated progressive leadership experiencePHYSICAL REQUIREMENTSFrequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.Frequent keyboard use/data entry.Occasional bending, stooping, kneeling, squatting, twisting and gripping.Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.Rare climbing.REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONSState of Work Location: IllinoisRegistered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)State of Work Location: MissouriRegistered Nurse (RN) Issued by Compact StateOrRegistered Nurse (RN) - Missouri Division of Professional RegistrationState of Work Location: OklahomaRegistered Nurse (RN) Issued by Compact StateOrRegistered Nurse (RN) - Oklahoma Board of Nursing (OBN)State of Work Location: WisconsinRegistered Nurse (RN) Issued by Compact StateOrRegistered Nurse (RN) - Wisconsin Department of Safety and Professional ServicesWork Shift:Day Shift (United States of America)Job Type:EmployeeDepartment:8746020033 Sys First Level Review Scheduled Weekly Hours: 40Benefits:Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay(fees may apply)before payday.Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law.