Manager, Registered Nurse – Utilization Management

This is a fully remote position, open to applicants in Illinois, +3 more states.

📋 Description

• Manage the daily operational activities of Utilization Management across the entire system.

• Create and lead a high-performing team in Utilization Management.

• Supervise departmental functions, including referrals, medical necessity evaluations, reviews of experimental/investigational procedures, and the application of medical policies and business processes.

• Ensure the quality and precision of Utilization Management decisions and compliance with departmental policies.

• Engage in policy formulation and oversee staff activities to ensure adherence to regulatory and accreditation standards.

• Oversee staff levels and productivity, adjusting staffing patterns to ensure sufficient operational coverage.

• Monitor budget compliance and approve or oversee expenditures and purchases.

• Ensure the Utilization Management team achieves performance metrics and meets work plan objectives.

• Represent Utilization Management in committees, task forces, work groups, and multidisciplinary teams.

• Assist in the development, maintenance, and compliance of Utilization Management programs and processes.

• Participate in organizational and departmental objectives, including quality enhancement initiatives.

• Recruit, engage, mentor, lead, and manage assigned staff members.

• Perform additional responsibilities as required.

⛳️ Requirements

• Extensive experience in Utilization Management or Case Management.

• Strong knowledge of CMS, Medicare & Medicaid, and Commercial regulations.

• Proven experience in leading large cross-functional teams at a management level.

• Experience in managing denials and appeals resolutions.

• Proficient in analyzing denial, authorization, and utilization data to identify trends and opportunities for improvement.

• Ability to adapt to change and foster a culture of continuous improvement.

• Demonstrated effective leadership through shifting priorities and organizational initiatives.

• Ability to cultivate accountability, collaboration, adaptability, and engagement within the team.

• Capability to be a trusted partner to staff, physicians, and operational leaders.

• Bachelor's degree in nursing.

• Two years of experience as an acute nursing registered nurse.

• Five years of experience in utilization management.

• At least two years of demonstrated progressive leadership experience.

• Required RN licensure/registration appropriate to the state of work location: Illinois RN license; Missouri RN issued by a compact state or Missouri RN license; Oklahoma RN issued by a compact state or Oklahoma RN license; Wisconsin RN issued by a compact state or Wisconsin RN license.

• Frequent lifting/carrying and pushing/pulling of objects weighing between 0–25 lbs.

• Regularly involves sitting, standing, walking, reaching, repetitive foot/leg and hand/arm motions, vision/depth perception, hearing and speech, as well as keyboard use/data entry.

• Occasionally involves bending, stooping, kneeling, squatting, twisting, gripping, and lifting/carrying or pushing/pulling objects weighing between 25–50 lbs.

• Rarely involves climbing.

🏝️ Benefits

• One week of paid parental leave for eligible team members for newborns or newly adopted children, pro-rated based on FTE.

• Flexible Payment Options through DailyPay, allowing eligible hourly team members instant access to earned, unpaid base pay (fees may apply).

• Upfront tuition coverage through FlexPath Funded for eligible team members.

• Comprehensive benefits package.