Manager, Utilization Management

Job Description Summary

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How will you make an impact & Requirements

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Primary duties may include, but are not limited to:

• Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.

• Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.

• Applies clinical knowledge to work with facilities and providers for care-coordination.

• May also manage appeals for services denied.

• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requirements:

• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.

• Minimum of 5 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

• Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

**This position is bonus eligible based on individual and company performance**

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Compensation:

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