Job description

POSITION SUMMARY:

The Nurse Manager for Utilization Review and Clinical Appeal Management is responsible for overseeing the daily operations of the Utilization Management (UM) and Clinical Appeal teams. This role ensures compliance with hospital policies, regulatory requirements, and payer guidelines while supporting efficient and effective utilization review and denial management processes. The Nurse Manager collaborates with interdisciplinary teams to reduce payer denials, improve reimbursement processes, and ensure high-quality patient care. Additionally, this role provides leadership, staff training, and quality improvement initiatives while fostering a collaborative and supportive work environment.

Position: Nurse Manager

Department: Utilization Review/Clinical Appeal Management

Schedule: 40 Hours (Days)

ESSENTIAL RESPONSIBILITIES / DUTIES:

1. Leadership & Operational Management

Collaborates with the Director to develop and implement Quality Assurance (QA) templates and conduct QA reviews.
Implements and assists the Director in chart audits to ensure compliance and efficiency.
Conducts regular one-on-one meetings with team members to provide support, coaching, and performance feedback.
Approves timekeeping and schedule changes in Kronos in the Director’s absence.
Works with the Director and staff to resolve employee relations issues, leveraging appropriate hospital resources.

2. Training & Professional Development

Provides comprehensive training for new staff and ongoing educational support for existing team members.
Leads and oversees the Unit-Based Council for the UM and Clinical Appeal teams.
Acts as a liaison between the UM/Appeal team and the Director for any scheduling concerns.
Communicates scheduling deadlines and manages time-off requests to ensure adequate staffing levels.

3. Utilization Review & Appeals Management

Serves as a resource to the UM and Appeal team for case-specific questions and complex cases.
Collaborates with interdisciplinary teams to reduce barriers for complex patients and improve hospital metrics.
Participates in reviewing and updating workflows, policies, and procedures annually with Director input.
Provides on-call weekend coverage (days/evenings) on a rotating basis with the Director.
Assumes partial UM and/or Appeal workload and provides coverage for staffing gaps as needed.

4. Quality & Compliance

Conducts performance improvement audits to assess quality of services against key indicators.
Ensures compliance with Medicare, Medicaid, and commercial payer regulations and hospital policies.
Analyzes and evaluates the impact of UM processes on clinical and financial outcomes.
Communicates with stakeholders regarding UM and appeal programs, providing data-driven insights and recommendations.

5. Team Development & Collaboration

Fosters a collaborative and supportive work environment that promotes teamwork, accountability, and continuous improvement.
Acts as a liaison with internal and external stakeholders, ensuring seamless communication and workflow efficiency.
Acts with a high level of independence in team leadership, determining appropriate next steps for inquiries and decision-making.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

Job Requirements

EDUCATION:

Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 yearsMast
Master’s Degree in Nursing or a health-care related field preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

Licensed to practice as a Registered Nurse in the Commonwealth of Massachusetts required
CCM or related certification attained within 24 months from the hire date is preferred

EXPERIENCE:

Required:

Minimum of 5 years of inpatient clinical nursing experience
Minimum of 3 years of utilization review and denials management experience

Preferred:

ACM-RN or CCM
Experience working with vulnerable patient populations
Clinical experience working with patients with multiple complex health issues
Progressive leadership experience

KNOWLEDGE, SKILLS & ABILITIES:

Strong leadership and team management skills, including mentoring, coaching, and conflict resolution.
Proficient knowledge of utilization management, denials management, performance improvement, and managed care reimbursement.
Analytical abilities to interpret and apply data for process improvement.
Strong problem-solving skills and the ability to work independently while exercising sound judgment.
Excellent verbal and written communication skills, with the ability to educate and collaborate with diverse teams.
Strong organizational and time management skills, with the ability to manage multiple priorities.
Proficiency in healthcare software systems, including electronic medical records (EMRs) and workforce management tools.
Understanding of hospital regulations, including compliance with Medicare, Medicaid, and commercial payer guidelines.

Equal Opportunity Employer/Disabled/Veterans

Required profile