Utilization Management Manager - RN

Roanoke, VA, US, 24015

Employment Status:  Full time
Shift:  Day/Evening
Facility:  Park View
Requisition Number:  124913

Job Summary

Directs the Carilion Medical Center's Utilization Management (UM) services. Coordinates departmental functions with hospital service lines to ensure adherence to Federal, State and payor rules and regulations regarding utilization management policy and procedures. Provides internal and external leadership for  the UM team focusing efforts on utilization review, denials management, and compliance regarding all UM processes and regulatory requirements.  Communicates, organizes, prioritizes, coaches, and problem solves with all members of the UM team to ensure appropriate and accurate  documentation that results in  support for appropriate placement and reimbursement for the level of services rendered for all  patients. Represents the Utilization Management department throughout the facility as requested. 

  • Establishes, implements, and evaluates departmental quality, service and productivity against benchmarks and scorecard measures which support Carilion Clinic and its strategic quality and process improvement initiatives. Establishes scorecard measures and operating plans for the UM function in collaboration with the CM Director. 
  • Manages open dialogue with staff physicians, internal and outsourced physician advisors, patients, clinical staff, and payer organizations to ensure adherence to all rules and regulations as well as payor contractual arrangements related to quality patient care and efficient management of Carilion resources.
  • Manages appropriate information for all  stakeholders in an ongoing, timely and accurate manner. Reviews and reports outliers within CMC to establish timely quality improvement initiatives. Establishes forums to engage in open, honest and proactive two-way communication.
  • Prepares, and monitors capital and operating budgets. Manages the Utilization Management functions in a fiscally responsible manner in compliance with Carilion policies and procedures. 
  • Directs, implements, and monitors organizational performance improving initiatives, such as  workflow process changes, staff training, audits, data analysis, and implementation of software tools and systems as directed by CMC. Conducts special projects as assigned by the Director of CM. 
  • Responsible for compliance with applicable licensure and accrediting standards, medical staff rules and regulations, and government/legal regulations as they relate to UM functions. Will organize and be a central participant in the Utilization Management Charter Team.
  • Manages all utilization review and denial and appeals staff. Establishes and reviews staffing plans to ensure effective resource utilization. Responsible for performance management and improvement.

Minimum Qualifications

Education: Bachelor’s or 8 years of equivalent experience. Master’s Degree and/or certification preferred.

Experience: Three years of management experience that demonstrates increased and/or diversified responsibility including responsibility for managing clinical and financial outcomes Must possess knowledge of UM functionality and accountability. Demonstrates knowledge of State and Federal rules and regulations that drive the UM process and scope of practice.

Licensure, certification, and/or registration: RN with current unrestricted license with the Virginia State Board of Nurse Examiners.

Other Minimum Qualifications: Ability to problem solve and to communicate effectively. Demonstrated effective leadership, training, and usage of interpersonal skills to manage a team of clinicians through change. Strong oral and written communication skills. Basic computer skills, knowledge of EPIC, Interqual, E-Discharge and Servo Formal training in utilization review criteria/processes highly desirable.

About Carilion

This is Carilion Clinic ...

An organization where innovation happens, collaboration is expected and ideas are valued. A not-for-profit, mission-driven health system built on progress and partnerships. A courageous team that is always learning, never discouraged and forever curious.

Headquartered in Roanoke, Va., you will find a robust system of award winning hospitals, Level 1 and 3 trauma centers, Level 3 NICU, Institute of Orthopedics and Neurosciences, multi-specialty physician practices, and The Virginia Tech Carilion School of Medicine and Research Institute.

Carilion is where you can make your own path, make new discoveries and, most importantly, make a difference. Here, in a place where the air is clean, people are kind and life is good. Make your tomorrow with us.


Requisition Number: 124913 
Employment Status: Full time 
Location: Park View 
Shift: Day/Evening 
Shift Details: Primarily Monday - Friday; 8 am - 4:30 pm
Recruiter: DANA E JOHNSON 
Recruiter Phone: 540-400-4631 
Recruiter Email: dejohnson@carilionclinic.org
For more information, contact the HR Service Center at 1-800-599-2537.

Equal Opportunity Employer

Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity

Carilion Clinic is a drug-free workplace.


Carilion Total Rewards

What matters to you is important to us—like benefits, rewards, and resources to improve your life. Carilion understands the importance of prioritizing your well-being to help you develop and thrive. When you make your tomorrow with us, we’ll enhance your potential to realize the best in yourself. Below are benefits available to you when you join Carilion:

  • Employer Funded Pension Plan, vested after five years (Voluntary 403B)
  • Comprehensive Medical, Dental, & Vision Benefits
  • Flexible Work Arrangements/Schedules
  • Remote Work Options
  • Paid Time Off (accrued from day one)
  • Onsite fitness studios and discounts to our Carilion Wellness centers
  • Access to our health and wellness app, Virgin Pulse
  • Discounts on childcare
  • Continued education and training

Find more about Carilion Clinic’s benefits by vising our Total Rewards Page.

Equal Opportunity Employer
Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity
Carilion Clinic is a drug-free workplace.

Nearest Major Market: Roanoke

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