Manager, Registered Nurse – Utilization Management

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

📋 Description

• Lead the team in delivering exceptional, cost-effective patient care.

• Supervise system-wide daily Utilization Management activities and services.

• Manage care coordination, utilization review, and initiatives for regulatory compliance.

• Oversee department operations, including referrals, medical necessity reviews, experimental/investigational reviews, and the application of medical policies and business processes.

• Ensure the quality and accuracy of Utilization Management review decisions while adhering to departmental policies.

• Participate in the development of policies and supervise staff activities for regulatory and accrediting compliance.

• Oversee staffing and productivity; adjust staffing patterns to ensure sufficient operational coverage.

• Monitor and ensure adherence to the budget; approve or oversee expenditures and purchases.

• Ensure the UM team meets performance metrics and fulfills work plan requirements.

• Represent UM on committees, task forces, work groups, and multidisciplinary teams.

• Assist in the development, maintenance, and adherence to UM programs and processes.

• Engage in quality improvement activities and contribute to company and department goals.

• Recruit, engage, develop, lead, and manage designated staff.

• Analyze the effectiveness of programs and staff.

• Perform additional duties as assigned.

⛳️ Requirements

• Bachelor's degree in nursing.

• Two years of acute nursing registered nurse experience.

• Five years of experience in utilization management.

• Two years of demonstrated progressive leadership experience.

• Extensive experience in Utilization Management or Case Management.

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

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

• Experience in managing denials and appeals resolutions.

• Experience in analyzing denial, authorization, and utilization data.

• Ability to promote continuous improvement and adapt to changing priorities.

• Ability to foster accountability, collaboration, adaptability, and engagement.

• Ability to partner effectively with staff, physicians, and operational leaders.

• Required RN licensure for the applicable work location: Illinois RN issued by IDFPR; Missouri RN issued by a compact state or Missouri Division of Professional Registration; Oklahoma RN issued by a compact state or Oklahoma Board of Nursing; Wisconsin RN issued by Wisconsin Department of Safety and Professional Services.

• Ability to meet stated physical requirements, including frequent lifting/carrying and pushing/pulling of 0–25 lbs, occasional 25–50 lbs, frequent keyboard use, and rare climbing.

🏝️ Benefits

• Paid parental leave: one week for eligible team members for newborns or newly adopted children, pro-rated based on FTE.

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

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

• Comprehensive benefits package.