State Licensed Utilization Management Nurse Supervisor

Job Summary

A company is looking for a Utilization Management Supervisor to lead a team of utilization review nurses and ensure high-quality clinical reviews.

Key Responsibilities

• Supervise and mentor a team of Utilization Review Nurses, providing guidance and training
• Collaborate with leadership to develop and maintain utilization management policies and clinical guidelines
• Conduct clinical reviews to assess medical necessity and ensure compliance with regulatory standards

Required Qualifications

• Five (5) or more years of Utilization Management or Quality Improvement experience in managed care
• Two (2) or more 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
• Familiarity with evidence-based criteria such as MCG and health plan policies