Regional Manager – Utilization Management

🕒 July 7

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Cleveland Clinic

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Cleveland Clinic is a not-for-profit, multispecialty academic medical center located in Cleveland, Ohio. Founded in 1921, it integrates clinical and hospital care with research and education, earning a reputation as one of the largest and most respected hospitals in the country. The health system includes multiple facilities across Northeast Ohio and other locations globally, providing a wide range of specialized services such as cancer care, women's health, dermatology, and cardiovascular care. Cleveland Clinic is accredited by The Joint Commission, which underscores its commitment to high standards in healthcare delivery.

📋 Description

• Manage the daily operations of Utilization Management, which includes concurrent and retrospective utilization review for medical necessity, collaboration and participation with the health care delivery team, review of utilization outcomes and related improvement activities. • Participate in departmental cost budgets and cost containment efforts. • Review and interpret patient population specific financial reports. • Recommend/implement resource utilization. • Prioritize and organize work to meet changing priorities. • Assist Senior Director as needed. • Oversee UM Specialists work load and projects. • Work independently to resolve issues within Utilization Management. • Utilize independent judgment to identify opportunities for improvement and coordinate projects to attain goals. • Provide direction and oversight for the UM Specialists daily activities and complete performance evaluations annually. • Hire and implement disciplinary action when needed. • Solve complex issues within Utilization Management and report results effectively using evidence-based practice framework. • Develop, recommend and initiate corrective action to avoid denials. • Analyze complex data sets to improve patient quality care/ financial outcomes.

🎯 Requirements

• Bachelor's degree in Nursing, Healthcare Administration or Business Administration • Completion of an accredited Registered Nursing RN Program • Proficiency with standard office equipment, including copiers, fax machines, personal computers, as well as Microsoft Office and clinical and financial computer systems • Three years of nursing clinical experience • Two years of recent Utilization Review/Care Management experience • One year of healthcare management experience • Current valid license in the State of Florida as a Registered Nurse (RN) • Basic Life Support (BLS) through American Heart Association (AHA) or American Red Cross • Working knowledge of multiple clinical areas, financial and data analysis, reimbursement practices, preadmission and concurrent review practices • Advanced understanding of payer issues • Experience with licensing and accreditation standards, regulatory standards, Utilization Review methodology and theory • Knowledge of multiple data base systems; clinical, financial and registration • Advanced knowledge of information, data, and project management • Advanced knowledge of unit operations, performance improvement/utilization management, regulatory and professional standards, evidence-based practice patient safety/risk management, and outcomes management • Strong clinical nursing experience and clinical judgment.

🏖️ Benefits

• We know that fully supporting our caregivers is what creates the best outcomes for our patients. Our outstanding, comprehensive offerings are an investment in your health, well-being and future.