Nov 29, 2021

Manager Utilization Management

  • The Children's Hospital of Philadelphia
  • Philadelphia, PA, USA

Job Description

Job Summary

Under the direction of the Senior Director, Case Management, the Manager Utilization Review (UR) has responsibility for oversight of the development, implementation and performance management of the Utilization Review and Denials Prevention program across all Children’s Hospital of Philadelphia (CHOP) acute hospitals. The Manager Utilization Management is responsible for utilization review and authorization management services, to promote appropriate level of care, length of stay, and prevent payer denials. Manages daily operations, which include supervising the staff performing utilization management and denial prevention activities. This role functions as the internal resource on issues related to utilization review and management. The manager is responsible for carrying out assignments in a manner to assure success in financial management, human resources management, leadership, quality and operational management objectives.

The manager consistently demonstrates the ICARE values of CHOP and serves as a role model to other employees.

Job Responsibilities

Essential Duties and Responsibilities:

  • Leading centralized utilization review team to effectively support revenue cycle process and denial prevention.
  • Directing CHOP implementation of new technology to support utilization review processes.
  • Lead successful denials prevention and performance improvement for CHOP hospitals.
  • Serve as CHOP case management lead with Managed Care Contracting to identify and address payer issues.
  • Collaborates with health care team partners on level of care, identified barriers, and other issues that may impact reimbursement. Collects data and other information required by payers to fulfill utilization and regulatory requirements.
  • Communicates with Case Management Medical Director all denials requiring a physician to physician conversation.
  • Ensures utilization management is in accordance with all state mandate regulations, understands and focuses on key performance indicators, and promptly reports potential denials to health care team.

Alignment with hospital leadership teams and consistently demonstrates ability to:

  • Develop strategies to manage and prevent disputes and improve Revenue Cycle processes with Revenue Cycle Directors and managers.
  • Build trusting relationships with hospital leaders to successfully implement new programs.
  • Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
  • Identify process inefficiencies via root cause analysis and design work flow to address opportunities identified
  • Develop and implement action plans managing follow up to achieve outcomes.
  • Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement.

Other Responsibilities:

  • Adheres to established departmental policies, procedures, and objectives.
  • Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
  • Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
  • Demonstrates a courteous and professional manner through interactions with internal and external customers.
  • Integrates scientific principles and research based knowledge in decision making.
  • Exemplifies a professional image in appearance, manner and presentation.
  • Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
  • Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
  • Performs other related duties as assigned.

Required Licenses, Certifications, Registrations

Registered Nursing License in the Commonwealth of Pennsylvania

Required Education and Experience

Required Education: Bachelor’s degree in Business, Nursing and/or Health Care Administration

Required Experience:

  • Registered Nurse with a minimum of three (3) years’ experience as clinical nurse in an acute care setting.
  • A minimum of five (5) years of hospital or health care leadership

Preferred Education, Experience & Cert/Lic

Preferred Education: MSN, MBA, or MHA


Preferred Experience:
• Prior experience as a Case Manager or Utilization Reviewer.
• Case Management Leadership role.

Preferred Certifications: Accredited Case Manager (ACM) or Certified Case Manager (CCM)

Additional Technical Requirements

  • Excellent communication skills and demonstrated organizational skills.
  • Knowledge of payor contracts and regulatory requirements.
  • Ability to work effectively with all departments and all levels of CHOP professionals.
  • Ability to work independently or within a team structure.
  • Must be very organized and able to work independently.
  • Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
  • Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).
  • Ability to effectively negotiate with internal and external providers of patient care services.
  • Sound problem solving and analytical skills.
  • Excellent customer service orientation and strong interpersonal skills.
  • Computer skills and a working knowledge of Word, Excel and PowerPoint.