Manager Utilization Review & Clinical Doc Improvement

This position will manage activities and staff of the Utilization Review department.

Supervise and evaluate the daily work of these teams in accordance with departmental and organizational policies. Provide education within the departments and the organization at large on clinical care, levels of care, and financial issues. Analyze and report data related to case management activities, payer activities, resource utilization, and clinical denials. Lead hospital wide initiatives on behalf of the department.

Monitor the performance, collection and analysis of data to report on the effectiveness of process improvement to the organization and department. Participate in the planning, development and implementation, and ongoing success of the Nurse Utilization Management Program. Educate members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members.

The Utilization Management Nurse Manager provides leadership, oversight, and operational management for the Utilization Management (UM) nursing team. This role ensures compliance with regulatory requirements, payer guidelines, and organizational policies while promoting high-quality, cost-effective, and patient-centered care. The Nurse Manager supports staff performance, workflow efficiency, and collaboration across interdisciplinary teams.

• Provide direct supervision, coaching, and performance management of UM nursing staff

• Foster a supportive, accountable, and collaborative team culture

• Support recruitment, onboarding, training, and professional development of UM staff

• Conduct regular staff meetings, performance evaluations, and competency assessments

• Oversee daily utilization review activities, including admission reviews, continued stay reviews, and discharge planning support

• Ensure appropriate documentation to support medical necessity and level-of-care determinations

• Monitor workflow, productivity, and quality metrics to ensure timely and accurate reviews

• Address escalations related to denials, delays, or complex utilization cases

• Ensure compliance with CMS, state, Joint Commission, and payer-specific requirements

• Maintain knowledge of InterQual, MCG, or other approved utilization criteria

• Participate in audits and regulatory surveys as needed

• Support denial prevention strategies and appeal processes in collaboration with physician advisors and revenue cycle teams

• Partner with physicians, physician advisors, case management, social work, finance, and revenue integrity teams

• Serve as a subject matter expert for utilization management practices and regulations

• Communicate effectively with payers and external partners when necessary

• Analyze utilization data, trends, and outcomes to identify opportunities for improvement

• Participate in performance improvement initiatives and system optimization

• Support reporting related to length of stay, denials, avoidable days, and payer performance

• Skills & Competencies

• Strong leadership, communication, and interpersonal skills

• Analytical and problem-solving abilities

• Ability to manage multiple priorities in a fast-paced environment

• Knowledge of healthcare regulations, reimbursement, and utilization review standards

• Commitment to patient-centered care and organizational values

Minimum Education
Master's Degree (Required)

Minimum Work Experience
7 years Healthcare experience (Required)
3 years Supervisory experience (Required)

Required Skills/Knowledge
Facile with keyboarding and familiar with software such as Windows environment (i.e., Microsoft Office, Word, PowerPoint, Excel, Access).
Excellent oral and written communication skills. Knowledge of children's health issues.
Knowledge of cultural issues and their impact on health care. Strong focus on Service Excellence.
Working experience with medical management criteria such as Milliman and/or Interqual.
Ability to analyze and present productivity and outcome data using Microsoft Access and Excel.

Required Licenses and Certifications
Registered Nurse in District of Columbia (Required)Basic Life Support for Healthcare Provider (BLS) (Required)
Case Management Certification (CCM or CMSA) (Preferred)

Functional Accountabilities
Operations Management - General

• Supervise and evaluate the daily work in accordance with departmental and organizational policies.

• Manage staffing to ensure adequate coverage and optimize productivity. Assign coverage and deploy staff accordingly.

• Participate in budget development and recommend budgets for areas of oversight.

• Track spending for areas of oversight.

Operations Management - Clinical Resource Management (CRM)/Utilization Review (UR)

• As a subject matter expert on Interqual and MCG guidelines, function as a resource to staff and intervene to resolve issues that arise internally and with payors.

• Mentor staff and support learning opportunities to foster success.

• Work directly with payors and Managed Care to enhance communication and improve authorization processes.

• Assist with the management of denials and High Risk cases

Relationship Building/Information Sharing

• Establish and maintain effective internal and external relationships to optimize achieving departmental and organizational goals.

• Provide information to Case Managers on organizational initiatives and professional trends in practice.

• Represent CRM on organizational committees.

Performance Improvement/Outcomes Management

• Ensure Case Management activities are in regulatory compliance (JC, CMS).

• Track clinical, functional, operational, quality and financial data related to CRM.

• Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.

• Implement processes to continually improve performance, reduce denials, and optimize reimbursement.

• Update Departmental procedures to reflect changes in payor contracts and departmental processes.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification
Teamwork/Communication
Performance Improvement/Problem-solving
Cost Management/Financial Responsibility
Safety

• Provide direct supervision, coaching, and performance management of UM nursing staff

• Foster a supportive, accountable, and collaborative team culture

• Support recruitment, onboarding, training, and professional development of UM staff

• Conduct regular staff meetings, performance evaluations, and competency assessments

• Oversee daily utilization review activities, including admission reviews, continued stay reviews, and discharge planning support

• Ensure appropriate documentation to support medical necessity and level-of-care determinations

• Monitor workflow, productivity, and quality metrics to ensure timely and accurate reviews

• Address escalations related to denials, delays, or complex utilization cases

• Ensure compliance with CMS, state, Joint Commission, and payer-specific requirements

• Maintain knowledge of InterQual, MCG, or other approved utilization criteria

• Participate in audits and regulatory surveys as needed

• Support denial prevention strategies and appeal processes in collaboration with physician advisors and revenue cycle teams

• Partner with physicians, physician advisors, case management, social work, finance, and revenue integrity teams

• Serve as a subject matter expert for utilization management practices and regulations

• Communicate effectively with payers and external partners when necessary

• Analyze utilization data, trends, and outcomes to identify opportunities for improvement

• Participate in performance improvement initiatives and system optimization

• Support reporting related to length of stay, denials, avoidable days, and payer performance

• Skills & Competencies

• Strong leadership, communication, and interpersonal skills

• Analytical and problem-solving abilities

• Ability to manage multiple priorities in a fast-paced environment

• Knowledge of healthcare regulations, reimbursement, and utilization review standards

• Commitment to patient-centered care and organizational values