Utilization Review Supervisor

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee virtual utilization review operations that enhance financial, quality, and clinical performance.

• Enhance the quality and completeness of medical record documentation.

• Employ proactive triggers to detect potential over- or under-utilization of services.

• Refer cases to the physician advisor and pinpoint barriers hindering patient progress.

• Execute daily medical necessity assessments for admissions, patient status, and ongoing stays.

• Conduct clinical reviews for inpatient and observation cases for commercial carriers within one business day post-admission.

• Communicate the results of reviews and collaborate with hospital liaisons on documentation, education, and level-of-care opportunities.

• Manage denial appeals, preserve appeal documentation, track denial trends, and report readmissions.

• Work in tandem with healthcare teams to meet outcomes management objectives, including CMS indicators.

• Maintain case management work queues and accurately document and submit statistical data.

• Lead multidisciplinary patient care initiatives and ensure continuity of care.

• Address benefit non-coverage issues and provide education to hospital and medical staff.

• Engage in process improvement teams, departmental meetings, conferences, committees, and task forces.

• Offer backup support to departmental staff and adhere to hospital, department, confidentiality, and patient rights policies.

⛳️ Requirements

• An active unrestricted RN license is mandatory.

• At least 1 year of leadership and/or coaching experience is required.

• A minimum of 2 years of utilization review experience is necessary.

• Over 5 years of nursing experience in an acute care setting is essential.

• Experience in utilization review and discharge planning is preferred.

• Recent knowledge of medical necessity review criteria is advantageous.

• Strong verbal and written communication skills are essential.

• Ability to collaborate effectively with all members of the care team.

• Strong clinical assessment, organizational, and problem-solving abilities are required.

• Capability to evaluate and identify suitable internal and community resources.

• Proficiency in working collaboratively with healthcare teams, providers, and payors.

• Skills in organizing information, prioritizing tasks, and completing multiple assignments effectively are necessary.

• Strong technical abilities, including proficiency in database and spreadsheet analysis.

• An Associate's degree in Nursing is required.

• A Bachelor's degree in Nursing is preferred.

• Current MCG certification or the willingness to obtain it within 6 months of hire is required.

🏝️ Benefits

• Bonus Incentives

• Paid Certifications

• Tuition Reimbursement

• Comprehensive healthcare, time off, retirement, and well-being benefits

• Career Advancement

• Professional certification relevant to the field for each associate

• Quarterly and annual incentive programs

• Work-life flexibility

• Remote work