Manager - Utilization Review Job at Acadia Healthcare (El Paso)

Manager, Utilization Review

Manager, Utilization Review for Care Management, remote in the United States. Pe...

Location

United States

Salary:

95000.00 - 105000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable)
Graduate of an accredited nursing program (ADN or diploma required
BSN preferred)
Knowledgeable of the Federal, State, DMHC, CMS and ERISA regulations
1-2 years in care management, utilization management, discharge planning, or related clinical coordination
Minimum 1 year of compliance related experience preferred
Certification in Case Management or Utilization Review preferred but not required
1+ year of informal leadership (preceptor/mentor/lead) or some direct people leadership
Working understanding of HIPAA, member rights, scope of practice, and documentation requirements
Comfort following policies and escalating risk/safety concerns appropriately

Job Responsibility

Supervise day-to-day operations of assigned Utilization Management staff, including scheduling, workload distribution, and adherence to established workflows
Provide full people management for assigned Utilization Management teams, including hiring, performance management, and staff development
Provide routine coaching, feedback, auditing, support and disciplinary action to ensure productivity, quality, and timeliness standards are met
Participate in hiring, onboarding, and training of Utilization Management staff
Monitor documentation for completeness, accuracy, timeliness and compliance with company policies and regulatory requirements
Escalate clinical, operational, and performance issues appropriately to leadership
Reinforce policies, procedures, and clinical guidelines through regular communication and staff education
Support audit readiness by ensuring staff compliance with documentation and timeliness standards
Maintain HIPAA compliance, confidentiality, and minimum necessary access at all times
Solid knowledge and understanding of medical necessity criteria across inpatient, outpatient, concurrent, and retrospective reviews, with the ability to coach staff on clinical rationale, documentation quality and timeliness

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions
Unlimited PTO
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets

Fulltime

Utilization Review Nurse Manager

The Utilization Review Nurse Manager will oversee a team responsible for managin...

Location

Philippines , Manila

Salary:

Not provided

NTT DATA

Expiration Date

Until further notice

Requirements

Typically requires 5- 9 years relevant experience
Should be open to work in night shifts
Undergraduate degree or equivalent combination of education and work experience
Solid communication skills
Demonstrated client service skills and leadership capabilities
Good knowledge, understanding and application of project management principles and methodologies
Models excellent analytical / problem solving skills
Good client service skills and leadership capabilities
Solid analytical / problem solving skills

Job Responsibility

Provides front-line supervision to an operational team of 35 or more employees
Supervised team typically responsible for manging US healthcare Payer claims adjudication process
Assigns work to direct reports
Recommends and takes actions hiring, firing, promotion, and disciplinary recommendations
Supervises team ensuring the highest quality of service is provided to clients
Monitors performance of the team and reports results and issues to higher-level leadership
Assists team with escalated client or account issues
Manages hiring, staffing and maintaining a diverse and effective workforce
Interacts with clients and internal departments to resolve issues
Works with the team to complete assignments using established guidelines, policies and procedures

Manager, Utilization Management Claims Review

The Manager, Utilization Management Claims Review is responsible for overseeing ...

Location

United States , Los Angeles

Salary:

117509.00 - 188015.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Bachelor's Degree in Nursing
In lieu of degree, equivalent education and/or experience may be considered
At least 6 years of experience in Clinical Nursing
At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
At least 4 years of leading staff, supervisor/management experience
Experience in performing and creating clinical documentation
Experience in regulatory compliance for a health plan
Experience leading teams, projects, initiatives, or cross-functional groups
Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement
Registered Nurse (RN) - Active, current and unrestricted California License

Job Responsibility

Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others
Ensure quality standards are met by regularly reviewing claim files, clinical decisions, and Provider Dispute Review (PDR) determinations to confirm compliance with company policies, clinical guidelines, and regulatory requirements
Identify trends or errors and implement improvements to increase accuracy and consistency
Establish team goals, monitor performance metrics, and ensure productivity and quality standards are met
Support recovery efforts and corrective action plans related to inappropriate billing or utilization patterns
Oversee workflow and queue management to ensure claims and PDR requests are completed within required regulatory timeframes, including monitoring workload distribution
Ensure adequate staffing resources and prevent backlogs or compliance risks
Ensure clinical policies are applied correctly and consistently, including policies designed to prevent fraud, waste, and abuse (FWA)
Potential FWA concerns are identified and escalated in partnership with Compliance and the Special Investigations Unit (SIU)
Support audits, regulatory readiness, and cross-functional initiatives to maintain compliance with state, federal, and accreditation standards

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Utilization Review Specialist - PRN

San Jose Behavioral Health is currently seeking a Utilization Review Specialist ...

Location

United States , San Jose

Salary:

33.00 - 60.00 USD / Hour

Acadia Healthcare

Expiration Date

Until further notice

Requirements

Associate Degree in Nursing(LPN/LVN/RN) Required
Two or more year's experience with the population of the facility preferred
Previous experience in utilization management is preferred
LMFT, LMSW, LCSW, LPC, LPC-Iwithin the state where the facility provides services
or current clinical professional license or certification, as required, within the state where the facility provides services
CPR and de-escalation and restraint certification required (training available upon hire and offered by facility)
Bachelors or Masters degree in Social Work, Behavioral Health Or Mental Health, Nursing or Other related health field preferred

Job Responsibility

Coordinate and assess the inpatient census for appropriate alternate health care service needs
Perform on-site and/or telephonic concurrent review of acute and sub-acute services, as well as pre-certification review for all services following the plans authorization guidelines
Coordinate with appropriate discharge planning processes, providing feedback on documentation processes
Function as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options
Act as liaison between managed care organizations and the facility professional clinical staff
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements
Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay
Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office
Conduct quality reviews for medical necessity and services provided
Facilitate peer review calls between facility and external organizations

Customer Success Utilization Manager

Drive adoption. Empower clinicians. Transform the Operating Room (OR) experience...

Location

United States , Louisville

Salary:

71000.00 - 92200.00 USD / Year

KARL STORZ

Expiration Date

Until further notice

Requirements

2–3 years of Operating Room, Sales, or Service experience (medical device or technical AV preferred)
Strong technical acumen and ability to translate complex systems into clear, actionable training
Exceptional communication, organizational, and relationship-building skills
Bachelor’s degree required (technical or healthcare focus preferred)
Passion for customer satisfaction, continuous learning, and driving measurable results
Willingness to travel 50% up to 80% regionally

Job Responsibility

Lead post-installation onboarding and project management for OR/Video integration systems
Deliver customized education, workflow optimization, and utilization strategies for clinical teams
Analyze usage data to drive adoption, performance, and product expansion opportunities
Conduct Quarterly Business Reviews with executive stakeholders to review key metrics and outcomes
Collaborate cross-functionally with sales, service, and product teams to ensure customer success
Continuously improve onboarding materials, documentation, and training programs

What we offer

Medical / Dental / Vision including a state-of-the-art wellness program and pet insurance
3 weeks vacation, 11 holidays plus paid sick time
Up to 8 weeks of 100% paid company parental leave
401(k) retirement savings plan providing a match of 60% of the employee’s first 6% contribution
Section 125 Flexible Spending Accounts
Life, STD, LTD & LTC Insurance
Tuition pre-imbursement up to $5,250 per year
Fitness reimbursement of up to $200 annually

Fulltime

Customer Success Utilization Manager

The Customer Success Utilization Manager (CSUM) is responsible for driving adopt...

Location

United States , Salt Lake City

Salary:

73600.00 - 95600.00 USD / Year

KARL STORZ

Expiration Date

Until further notice

Requirements

2–3 years in OR sales, service, or technical roles, or 1+ year of KARL STORZ video and integration service/support experience, or equivalent technical or operating room experience
Bachelor’s degree with demonstrated technical aptitude, or equivalent combination of education and experience
Strong leadership, communication, and organizational skills
Consultative mindset with intellectual curiosity and creativity
Proven ability to work cross-functionally in a matrixed environment
High ethical standards, adaptability, and comfort in fast-paced or ambiguous situations
Strong customer satisfaction track record

Job Responsibility

Lead regional post-installation execution for OR and Video Tower projects, ensuring on-time, successful go-live
Manage post-installation plans, progress, documentation, and customer feedback
Act as primary consultant to define and deliver customer-specific success outcomes following installation
Analyze usage data and customer metrics to drive adoption and identify expansion opportunities
Design and implement customized utilization, training, and adoption plans across hospital enterprises
Conduct Quarterly Business Reviews with customer leadership to review performance, utilization, and growth opportunities
Onboard and train physicians, clinicians, and staff across all sites of care
Deliver customized, product-specific training and demonstrations of procedural applications
Provide expertise on hardware, software, integrations, upgrades, and use cases
Serve as expert on video, integration, and OR1 room management solutions

What we offer

Medical / Dental / Vision including a state-of-the-art wellness program and pet insurance, too!
3 weeks vacation, 11 holidays plus paid sick time
Up to 8 weeks of 100% paid company parental leave
includes maternal/ paternal leave, adoption, and fostering of a child.
401(k) retirement savings plan providing a match of 60% of the employee’s first 6% contribution (up to IRS limits)
Section 125 Flexible Spending Accounts
Life, STD, LTD & LTC Insurance
We prepay your tuition up to $5,250 per year! - Tuition pre-imbursement
Fitness reimbursement of up to $200 annually

Fulltime

Medical Director of Case Management and Utilization Review

The Medical Director of Case Management and Utilization Review leads the hospita...

Location

United States , Miramar

Salary:

Not provided

Memorial Healthcare System

Expiration Date

Until further notice

Requirements

Medical Doctor (Required)
Medical Doctor License (ME LICENSE) - State of Florida (FL)
Osteopathic Physician License (OS LICENSE) - State of Florida (FL)
Extensive experience in one or more branches of medicine or surgery
at least, five (5) post-training years of medical staff organization/administrative experience in a large acute care hospital
Graduate of a medical school approved by the Council on Medical Education of the American Medical Association
Excellent customer service and interpersonal skills
Able to effectively present information, both formal and informal
Strong written and verbal communications skills with all levels of internal and external customers
Strong analytical skills

Job Responsibility

Supports education and clinical documentation improvement
Leads Complex Care Management
Leads hospital initiatives to reduce complex patient length of stay
Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation stay
Provides peer review services for medical necessity of admission or continued stay
Supports the Senior Medical Director in Medical Staff Education
Assists physicians in improving the quality of their medical necessity documentation
Serves as liaison to insurance companies for prior authorizations and removes barriers to discharge
Supports case management by attending interdisciplinary rounds (IDR) and provides feedback and suggestions to physicians and CMs
Serves as liaison to case management, social workers, nursing staff, individual physicians, and the medical staff

Fulltime

Utilization Review Nurse-LVN/LPN

Under the supervision of a registered nurse the Utilization Review Nurse will pr...

Location

United States

Salary:

25.00 - 29.00 USD / Hour

Personify Health

Expiration Date

Until further notice

Requirements

Current LVN license in the United States or U.S. territory
1+ years of clinical experience
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Must be able to remain in a stationary position 50% of the time
The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities
Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
Frequently positions self to maintain files in file cabinets

Job Responsibility

Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity
and all post claim or post service reviews
Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
Refer requests that fall outside of established guidelines to advance review or senior care consultants
Process appeals for non-certification of services
complete non-certification letters when appropriate
Review plan document for benefit determinations
attempt to redirect providers and patients to PPO providers

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Paid Time Off—rest and recharge time is non-negotiable
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact on people's health

Fulltime

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Manager - Utilization Review

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