Manager Clinical Utilization Management RN (waukesha WI)

Manager Of Clinical Utilization Management

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Manager of Clinical Utilization Management is responsible for leading and optimizing the hospital's utilization review processes to ensure appropriate use of medical resources, regulatory compliance, and alignment with clinical best practices. This role plays a critical part in managing acute hospital utilization, preventing payer denials, and minimizing net revenue leakage. The manager oversees a team of utilization review nurses and analysts, collaborates with interdisciplinary teams, and drives initiatives that support efficient, high-quality patient care.

Primary Responsibilities:

• Lead and manage the daily operations of the utilization management team, including staffing, scheduling, and performance oversight
• Oversee acute hospital utilization review processes to ensure timely and accurate determinations of medical necessity and level of care
• Monitor and enforce compliance with CMS, commercial payer guidelines, and hospital policies
• Collaborate with physicians, case managers, and revenue cycle teams to proactively address documentation gaps and prevent payer denials
• Develop and implement strategies to reduce length of stay, avoidable days, and unnecessary resource utilization
• Analyze utilization data to identify patterns of net revenue leakage and implement corrective actions
• Serve as a liaison with payers and external review organizations to resolve disputes and facilitate approvals
• Provide education and training to clinical staff on documentation standards, medical necessity criteria (e.g., InterQual, MCG), and regulatory requirements
• Lead initiatives to improve denial management processes and enhance revenue integrity
• Prepare and present utilization and financial impact reports to hospital leadership
• Participate in hospital committees focused on quality, compliance, and performance improvement

Working Conditions:

• Full-time position based on-site at the hospital campus
• May require occasional evening or weekend hours to support operational needs or attend meetings
• Fast-paced clinical environment with frequent interdisciplinary collaboration

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Registered Nurse (RN) with an active, unrestricted RN License in the state of Wisconsin
• 5+ years of experience in utilization review or case management in an acute care setting
• 2+ years of supervisory or management experience with demonstrated ability to communicate, analyze, and effectively lead teams
• Experience with revenue cycle processes and financial impact analysis
• Knowledge of InterQual/MCG criteria, CMS regulations, payer guidelines, and denial prevention strategies
• Proficiency in electronic medical records and utilization management software
• Live in the Waukesha WI Regional Area (this is an onsite position, not open to remote/telecommute work)
• Able/willing to work onsite in a hospital environment daily

Preferred Qualifications:

• Certification in Utilization Management or Case Management (e.g., ACM, CCM)
• Epic experience
• Experience working in healthcare payer operations

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $89,900 to $160,600 annually based on full-time employment. We comply with all minimum wage laws as applicable.