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United States
Remote only
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Utilization Review Manager based in United States.
This is a strategic clinical leadership role overseeing a centralized Virtual Utilization Management program in a complex healthcare environment. You will lead teams responsible for utilization review, authorizations, denials, and appeals across inpatient, observation, and outpatient services. The role combines clinical expertise with operational leadership, regulatory compliance, financial accountability, and continuous process improvement. You will collaborate with hospital-based leaders, physicians, care coordination, clinical documentation, coding, and revenue cycle teams to improve outcomes and reduce unnecessary costs. A key focus will be optimizing length of stay, strengthening denial and appeal performance, and maintaining high standards of program compliance. This remote opportunity is ideal for an experienced nursing and utilization management leader who is comfortable driving change, developing teams, and leveraging technology and AI to improve healthcare operations.
Lead and manage the centralized Virtual Utilization Management program, ensuring clinical and operational excellence across utilization review activities.
Oversee utilization management processes covering inpatient and observation/outpatient authorization, denials, and appeals.
Develop annual utilization management work plans aligned with strategic priorities and departmental goals, and report progress to senior leadership.
Provide operational leadership and resources to virtual utilization management teams while supporting Care Coordination and Clinical Documentation functions.
Partner with hospital-based utilization management leaders, physician advisors, physicians, nurse practitioners, physician assistants, Care Coordination, Coding, Clinical Documentation, Health Information Management, and Revenue teams.
Develop and implement strategies to reduce inappropriate denials, improve appeal outcomes, address failed billing issues, and optimize reimbursement.
Drive initiatives to reduce excess inpatient days and improve overall length of stay through effective utilization management and interdisciplinary collaboration.
Monitor staffing productivity, team effectiveness, program performance, and compliance, taking corrective action when needed.
Ensure utilization management practices comply with applicable state regulations, Medicare and Medicaid requirements, insurance regulations, and organizational policies.
Apply MCG or comparable clinical criteria appropriately when evaluating medical necessity and utilization decisions.
Identify process redesign opportunities that improve efficiency, eliminate unnecessary work, and strengthen clinical and financial outcomes.
Lead studies, committees, and improvement initiatives designed to demonstrate measurable progress in denial, appeal, utilization, and patient-flow outcomes.
Identify employee development opportunities, support performance management, and maintain an active engagement and development plan for utilization management staff.
Manage departmental budgets in partnership with senior utilization management leadership, including staffing requirements, resource planning, and future growth needs.
Review monthly budget and operational reports, identify variances, and develop action plans to maintain financial and performance targets.
Explore and apply AI-enabled technologies and process improvements to increase operational efficiency and support better utilization management outcomes.
Travel to client, temporary, or corporate locations when business requirements call for onsite support.
Associate degree in Nursing is required; a Bachelor’s degree in Nursing is preferred.
Current unrestricted nursing license in the state of residence.
MCG certification is required within six months of hire.
Significant experience in utilization management, clinical review, denials and appeals, care coordination, or a related healthcare operations function.
Strong knowledge of MCG or other recognized medical-necessity criteria and their application in utilization review.
Broad understanding of insurance requirements, Medicare and Medicaid regulations, and applicable state and regulatory guidelines.
Demonstrated experience managing clinical or utilization management teams and monitoring productivity, quality, and operational effectiveness.
Strong understanding of healthcare revenue cycle processes, particularly the relationship between utilization management, length of stay, clinical documentation, denials, appeals, and reimbursement.
Proven ability to make informed decisions by gathering, analyzing, and interpreting complex information and evaluating multiple options.
Strong problem-solving skills and sound judgment, with the confidence to address difficult issues and make timely decisions.
Excellent influencing, negotiation, communication, and stakeholder-management abilities across clinical and business functions.
Demonstrated ability to coach, develop, and motivate team members while fostering engagement and professional growth.
High emotional intelligence and the ability to establish trusted relationships with employees, physicians, leaders, and cross-functional partners.
Strong commitment to creating an inclusive environment that values diverse perspectives, backgrounds, and working styles.
Excellent organizational and documentation skills, with strong attention to detail and a high level of integrity, confidentiality, and compliance.
Strong computer skills, particularly with databases, spreadsheets, reporting, and data analysis.
Demonstrated interest and advanced experience using AI to improve processes, technology adoption, and team effectiveness.
Ability to work independently in a fast-paced environment while managing competing priorities.
Willingness and ability to travel and work onsite at client or corporate locations when business needs require.
Must reside in and be authorized to work in the United States.
Full-time, remote position with nationwide eligibility for U.S.-based candidates.
Base salary range of $92,400 to $138,600, depending on experience and other job-related factors.
Bonus and incentive opportunities.
Comprehensive healthcare and benefits package supporting physical, emotional, and financial well-being.
Paid time off and retirement benefits.
Professional development opportunities and paid certifications relevant to your field.
Tuition reimbursement.
Career advancement opportunities within a growing healthcare services environment.
Quarterly and annual recognition and incentive programs.
Work-life flexibility and a culture focused on collaboration, growth, innovation, and employee well-being.
Opportunities to contribute to technology-enabled healthcare transformation and AI-driven process improvement.
Exposure to complex utilization management, revenue cycle, clinical, and operational initiatives across healthcare organizations.