✨ About The Role
- Supervise Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members
- Monitor and track UM resources to ensure adherence to performance, compliance, quality, and efficiency standards
- Collaborate with utilization management team to resolve complex care member issues
- Develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services
- Evaluate utilization management team performance and provide feedback regarding performance, goals, and career milestones
âš¡ Requirements
- Experienced clinical professional with a background in nursing or a related field, ideally with 5-8 years of experience in utilization management
- Strong leadership skills to supervise and mentor a team of clinical review nurses, ensuring adherence to quality and performance standards
- Ability to collaborate with senior management to identify opportunities for process and quality improvements within utilization management
- Detail-oriented individual with knowledge of regulations, accreditation standards, and industry best practices related to utilization management
- Excellent communication skills to educate and provide resources for the utilization management team, members, and providers