Manager, Utilization Review

Job ID: J120425
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 7, 2018

Share:

Description

GENERAL OVERVIEW:

The Manager of Utilization Review is responsible for overseeing system-wide utilization activities. This position supports the Director in the daily operational and clinical priorities.

ESSENTIAL RESPONSIBILITIES:

  • Oversight of the review process for patient services, monitor and trend timeliness of UR decision making, acts as a resource in all issues relating to utilization review. (20%)
  • Day-to-day direction to Utilization Review staff, including maintenance of adequate staffing, assurance of adequate staff training and ongoing education, and payroll duties. (15%)
  • Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care, provides direction to the operations of referral management, telephone and onsite utilization management activities. (15%)
  • Prior authorization functions inclusive of the timely notification of high quality decisions. (15%)
  • Develop proactive processes for upfront reviews of new admissions / transfers, including appropriate and complete registration, insurance verification and authorization verification. (15%)
  • Along with the Director, oversight and monitoring of the peer review process, ensuring timeliness of completion throughout Network. (10%)
  • Responsible for all UR audits, inclusive of completing roadmaps and preparing files. (5%)
  • Provides clinical support and communicates with departmental and administrative staff to facilitate daily department functions in accordance with guidelines. (5%)

QUALIFICATIONS:

Minimum

  • Bachelor's degree in a health related field
  • Current PA RN license
  • 5 years Utilization Review related experience or 5-7 years acute care nursing experience
  • 5 years in a managed care environment
  • 5 years of progressive management experience with proven results

Preferred

  • BSN degree
  • Certificate in Case Management

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

Registered Nurse, CTICU/PCU

Pittsburgh, PA, United States
Nursing

Registered Nurse- PCU (Full-Time)

Monroeville, PA, United States
Nursing

Utilization Reviewer RN

Pittsburgh, PA, United States
Nursing

Nurse Navigator - Oncology - AGH

Pittsburgh, PA, United States
Nursing

Outpatient Infusion Nurse - Oncology- Beaver

Butler, PA, United States
Nursing

Outpatient Registered Nurse- Primary Care- Crafton

Pittsburgh, PA, United States
Nursing

Nurse Navigator- Cardiology- AGH

Pittsburgh, PA, United States
Nursing

Registered Nurse, Med/Surg ICU

Pittsburgh, PA, United States
Nursing

Registered Nurse, CTICU/PCU

Pittsburgh, PA, United States
Nursing

Registered Nurse, Med/Surg ICU

Pittsburgh, PA, United States
Nursing

Registered Nurse, ICU/CCU

Natrona Heights, PA, United States
Nursing

Registered Nurse- Medsurg/Oncology

Natrona Heights, PA, United States
Nursing

RN Clinical Supervisor- Internal Medicine- Federal North

Pittsburgh, PA, United States
Nursing

Outpatient Registered Nurse- Primary Care- Cranberry

Cranberry, PA, United States
Nursing

Outpatient Registered Nurse- Primary Care- Gibsonia

Gibsonia, PA, United States
Nursing

RN orthopedic Navigator

Erie, PA, United States
Nursing

Outpatient Registered Nurse- Primary Care- Verona

Verona, PA, United States
Nursing

Instructor School of Nursing

Pittsburgh, PA, United States
Nursing

Registered Nurse- Med/Surg

Monroeville, PA, United States
Nursing

Registered Nurse - Short Stay Unit (Days)

Erie, PA, United States
Nursing

Graduate Nurse- Multiple Units

Canonsburg, PA, United States
Nursing

Outpatient Registered Nurse - Cardiology - Clarion

Clarion, PA, United States
Nursing