Clinical Utilization Manager
4 weeks ago
As a Clinical Utilization Manager at Medicine Journal, you will play a crucial role in ensuring the efficient use of healthcare resources. You will interact with interdisciplinary staff to complete the process of utilization management, ensuring that patients receive the necessary care while minimizing unnecessary costs.
Education:
Required:
A graduate degree in Nursing from an accredited institution is essential for this role. You must have a strong foundation in clinical knowledge and be familiar with regulatory and insurance reimbursement issues.
Preferred:
Experience:
Required:
At least five years of broad clinical experience, with prior experience in utilization management preferred. You should have a minimum of three years of experience in managed care practices and demonstrate evidence of clinical knowledge and familiarity with regulatory and insurance reimbursement issues.
Preferred:
Position Requirement(s): License/Certification/Registration
Required:
A current license to practice nursing in the State of Tennessee is mandatory. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.
Preferred:
Prior experience in utilization management is highly desirable. You should have knowledge of managed care practices and a minimum of three years of experience, with evidence of clinical knowledge and familiarity with regulatory and insurance reimbursement issues.
Department Position Summary:
This role involves the initial and concurrent review of patient records, obtaining information from physicians during patient encounters to determine medical necessity, and continued length of stay. You will also be responsible for observation management and capturing avoidable days, participating in performance improvement activities, and taking responsibility for department and organization objectives.
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