Manager, Utilization Management

• Leads teams responsible for oversight of staff and daily operations within the Utilization Management (UM) department
• Provides training, guidance, and support to direct reports
• Ensures regulatory compliance
• Contributes to UM programming across the UVM Health
• Ensures quality outcomes in medical necessity review, appeals, denials, and patient status determination
• Coaches and mentors team members to enhance performance
• Promotes a positive work environment that supports staff engagement
• Leads change initiatives
• Encourages professional development and continuous learning
• Communicates complex clinical requirements clearly to staff and stakeholders
• Applies Medicare, Medicaid, and CMS regulations accurately
• Ensures compliance with JCAHO and HIPAA requirements
• Maintains up-to-date knowledge of UM policies and guidelines
• Educates staff on regulatory updates and expectations
• Evaluates clinical data to determine appropriate patient status
• Makes sound decisions in complex utilization review cases
• Identifies issues and develops solutions proactively
• Analyzes trends to inform process improvement efforts
• Builds effective relationships with care management and clinical teams
• Partners with internal and external stakeholders to optimize UM operations
• Facilitates cross-functional communication and teamwork
• Demonstrates respect and cultural competence in all interactions
• Takes ownership of departmental goals and outcomes
• Ensures timely completion of tasks and adherence to timelines
• Monitors performance indicators and implements corrective strategies as needed
• Demonstrates reliability and consistent follow-through

• Bachelor’s Degree in Nursing required
• Master’s degree in nursing or experience equivalent preferred
• Current and Active Registered Nurse (RN) license
• CM certification preferred
• Case management accreditation required by a nationally recognized accrediting body for case management (examples: CCM, ACM or ANCC certifications), preferred
• Experience working within a unionized environment preferred
• 3-5 years of leadership experience in a healthcare setting required
• 3-5 years of clinical experience in a healthcare setting (or equivalent) required
• Care Management/Care Coordination experience required

• Master’s degree in nursing or experience equivalent preferred
• CM certification preferred
• Case management accreditation preferred
• Experience working within a unionized environment preferred

Comprehensive, total compensation package that includes salary, health and wellness benefits, paid time off, and more