Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
The Utilization Management (UM) Nurse is a licensed nursing professional responsible for reviewing UM cases and discharge planning activities. The UM Nurse may also assist with preparing files for audits and required reporting and ensuring UM cases are reviewed and processed within timeliness standards.
The UM Nurse will work closely with the UM/QI Manager, MSO UM team, MSO Medical Director, and MSO Physician Reviewer on UM case reviews. The UM Nurse will also work with the MSO Case Management team on coordinating patient care to ensure patients can access the necessary medical care to manage their health condition.
This is an FLSA Exempt position.
This is not an OSHA high-risk position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
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