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Manager - Utilization Review

Baptist Health Care
United States, Florida, Pensacola
Jun 26, 2025
Job Description The Utilization Management Review Manager provides a key role in facilitating long-term success of the UM program by providing day-to-day intense oversight of Utilization Management at the facility level. The Utilization Management Review Manager supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The Utilization Management Review Manager will work in collaboration with the clinical documentation improvement and utilization management team of clinicians, coding professionals, physicians, physician's assistants' and certified registered nurse practitioners to ensure accurate and timely clinical documentation in the medical record that supports the admission status and coding process in attaining sound clinical entries in the medical record. Specific management of care collaboration includes observation utilization and denial management. The Utilization Management Review Manager is responsible for increasing program awareness (Utilization process and program benefits) to the entire hospital staff. The Utilization Management Review Manager must fully understand data collection and analysis for hospital use of professional services. The Utilization Management Review Manager will support ongoing communication and education on documentation opportunities, utilization review, coding and reimbursement issues, as well as performance improvement methodologies to physicians and entire hospital staff. The Utilization Management Review Manager will function as the UM Committee co-chair and participate in CDMP Task Force (CDMP team) meetings. Responsibilities Accountability for Utilization Management Program Success. Responsible for maintaining effective and efficient processes for determining the appropriate admission status. Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status. Develops a collaborative clinical documentation improvement and utilization management teams. Functions as the UM committee co-chair member. Provides utilization review and CDI team, physicians, administration and UM committee ongoing feedback. Creates and disseminates reports from electronic tools and formulates action plans based on results. Assist with preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials. Develops strategies that address program initiatives and prevent denials. Facilitate the annual update of InterQual (or other screening tool) software (collaborating with Information Systems staff), create training tools, and provide training to RN CMs. Manages multiple priorities effectively. Is responsible for department's operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards. Is responsible for the fiscal management of department; assures proper utilization of organization's financial resources. Manage team members which include orientation, development and evaluation of personnel, and monitoring the provision of delivering quality services. Participates in the recruiting, interviewing and selecting of team members following policies, guidelines and applicable laws. Evaluates their performance relative to job goals and requirements. Provides coaching to staff, recommends in-service education programs, and ensures adherence to internal policies and standards. Effectively communicates departmental, organization, and industry information to staff. Maintains current knowledge/certification. Pursues professional growth and development. Qualifications Minimum Education Associates Degree Nursing Required Bachelor's Degree Nursing Preferred Minimum Work Experience 5 years clinical and/or coding adult acute care experience in Med Surg, Critical Care, Emergency Room or PACU. Required 1-3 years case management and/or utilization review experience. Required 2 years management or supervisory, leadership experience. Required Licenses and Certifications Registered Nurse Licensed State of Florida or eligible compact license Upon Hire Required Required Skills, Knowledge and Abilities Organizational, analytical, writing and interpersonal skills. Excellent knowledge of Word/Excel/Power Point. Knowledge of Medicare Part A and Part B. Knowledge of ICD-10, DRG and other hospital reimbursement methodology Knowledge of regulatory environment. Understand and support Utilization Review strategies. General understanding of hospital-based quality initiatives (preferred). Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (training provided.) Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law.