State Licensed Utilization Management Supervisor

Job Summary

A company is looking for a Supervisor of Utilization Management to lead a team of utilization review nurses.

Key Responsibilities

• Supervise and support a team of Utilization Review Nurses, providing guidance, mentorship, and ongoing training
• Collaborate with leadership to develop, implement, and maintain UM policies, procedures, and clinical guidelines
• Conduct clinical reviews to assess medical necessity and appropriateness of services, ensuring compliance with regulatory requirements

Required Qualifications

• 5+ years of Utilization Management or Quality Improvement experience in managed care
• 2+ years of clinical experience in an acute care or surgical hospital setting
• Active RN license in the state of residence
• Proficient in ICD-10, CPT, HCPCS, Revenue codes, and CMS/URAC guidelines
• Familiar with evidence-based criteria such as MCG and health plan policies