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The Utilization Management (UM) Manager is responsible for managing day-to-day UM operations within the markets, focusing on effective team management, authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. Act as a working manager within Utilization Management, performing essential duties and responsibilities (utilization reviews, denials, and authorizations) in non-represented markets, with a time allocation of no more than 40% of the total work hours. Ensure a balance between management and operational responsibilities to maintain effective team leadership and oversight. This role supports the UM Director in ensuring efficient operations with all processes, policies, strategies and ensuring compliance with all regulatory and payer requirements.

ESSENTIAL KEY JOB RESPONSIBILITIES
1. Assist with daily operations of care coordination, including effective staff supervision, and resource allocation to align with organizational goals.
2. Oversee staff recruitment, performance evaluation, coaching, mentoring, and professional development, ensuring a high-performing team aligned with organizational objectives.
3. Oversee daily operations to ensure effective utilization reviews, strict adherence to denial management processes, and compliance with established policies and procedures.
4. Ensure prompt and accurate processing of payer communications and authorizations through efficient management by the UM staff.
5. Train and mentor UM staff to promote high performance and adherence to regulatory and organizational standards.
6. Monitor staff performance continuously, identify training needs, and implement development plans to address performance gaps.
7. Foster collaboration with healthcare providers to ensure timely and accurate documentation, essential for successful appeals and audits.
8. Facilitate robust communication channels between UM staff, healthcare providers, and payers to swiftly resolve issues and maintain clarity in processes.
9. Regularly report on key performance indicators (KPIs), analyzing data to develop actionable plans for addressing areas of concern in utilization management activities, patient outcomes, and resource utilization.
10. Monitor, analyze, and report on the efficacy of UM activities to inform strategic decision-making and promote continuous improvement.

11. Ensure that the utilization management department complies with all relevant healthcare regulations, accreditation standards, and organizational policies.
12. Serve as the primary liaison for medical, administrative, and regional staff, as well as external regulatory bodies, ensuring compliance with federal, state, TJC, DNV, and other regulatory requirements.
13. Implement policies and procedures to align with industry best practices and regulatory changes.
14. Performs essential duties and responsibilities in utilization management (utilization reviews, denials, and authorizations) in non-represented markets, with a time allocation of no more than 40% of the total work hours.
15. Ensure a balance between supervisory and operational responsibilities to maintain effective team leadership and oversight.

Required Education and Experience:

● Bachelor's degree in Nursing, Health Care Administration or related clinical field
● Minimum 5 years of clinical case management (Utilization Management, Denial Management, Care Coordination)
● Minimum 3 years management experience in a clinical case management department. (Utilization Management, Denial Management, Care Coordination)

Preferred Education and Experience:

● Master's degree in Nursing, Health Care Administration or related clinical field preferred.
● Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services

Required Licensure and Certifications:

● Current unrestricted RN license where practicing required.
● National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within 2 years upon hire.

Required Minimum Knowledge, Skills, Abilities and Training:

● Comprehensive knowledge of utilization management, Medicare, Medicaid, and commercial admission and review requirements.
● In-depth knowledge of utilization management processes and best practices.
● Strong managerial and decision-making skills.
● Excellent communication skills and the ability to work collaboratively.
● Proficient in healthcare IT systems relevant to utilization management.
● Effective leadership and team-building skills.
● Excellent organizational and communication skills.
● Ability to work under pressure and manage multiple priorities.
● Knowledge of CMS standards and requirements.
● Ability to work as a team player and assist other members of the team where needed.

#LI-CHI

Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area.