Utilization Management Job Description

Utilization Management Job Description

164 votes for Utilization Management
Utilization management provides swift attention to planning and action based on impactful changes in the market, regulations, managed care contracting, etc.

Utilization Management Duties & Responsibilities

To write an effective utilization management job description, begin by listing detailed duties, responsibilities and expectations. We have included utilization management job description templates that you can modify and use.

Sample responsibilities for this position include:

Collaborate with peers in Medical Management, Quality Management, Grievance and Appeals
Develop, revise, and implement Utilization Management (UM) policies and procedures
Implement and manage effective UM processes that results in cost efficient utilization of services
Manage pre-authorization, concurrent review, and retrospective review processes for all inpatient, outpatient and services
Develop and maintain processes for ensuring inter-rater reliability among all reviewers
Implement process for oversight of all delegated UM vendor services
Develop and support relationships with providers that result in continued improvement in quality healthcare outcome
Perform all duties inherent in a managerial role
Participate in special projects and perform other job duties
Learn and use tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed

Utilization Management Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Utilization Management

List any licenses or certifications required by the position: CCM, ACM, CPR, BLS, AHA, UM, GOLD, MCG, MS, CM

Education for Utilization Management

Typically a job would require a certain level of education.

Employers hiring for the utilization management job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Education, Nursing, Management, Healthcare, Medical, Performance, Pediatrics, Health Care, Health, Business

Skills for Utilization Management

Desired skills for utilization management include:

Microsoft Word
Medical terminology
Outlook and Excel
Managed care principles
HMO and Risk Contracting arrangements
Insurances and managed care
Health care resources within the community
Milliman Criteria

Desired experience for utilization management includes:

Develop a working familiarity with applicable regulatory and accreditation requirements
Participate in quality improvement activities as requested
Provide feedback into improving the company's overall operations and member/provider experience
Obtaining pre-certification and continued stay authorizations on behalf of the patient and provider, using American Society of Addiction Medicine (ASAM) criteria to review clinical information with insurance companies
Performing “peer to peer” reviews and appeals with insurance company Doctors / Medical or Clinical Directors
Communicating authorization information

Utilization Management Examples


Utilization Management Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of utilization management. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for utilization management
  • Processes or obtains authorizations/certifications based on payer contracts
  • Promotes cohesiveness and peer support among department staff and colleagues
  • Work prebill accounts identified via the Meditech reports efficiently and effectively on a daily basis to resolve accounts with “no auth numbers and ALOS vs
  • Document actions taken on the account clearly and concisely
  • Contacting the facilities, physicians’ offices and/or insurance companies to resolve denials/appeals
  • Adhere to all policies and procedures, including phone and internet usage, break utilization
  • Participate in ongoing education and training as needed
  • Adheres to established policy and procedure and escalates issues through the established Chain of Command
  • Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with “no auth
  • Numbers, ALOS vs
Qualifications for utilization management
  • Works in an environment where there is some discomfort due to dust, noise, temperature
  • Knowledge of the Nurse Practice Act, JCAHO, NCQA, and other local, state, and federal regulations
  • Demonstrated skills in leading and facilitating the efforts of multidisciplinary groups
  • Demonstrated strong communication, problem-solving and analytical skills
  • Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting
  • Initiates Discharge Follow-up Calls as per protocol and refers appropriate cases to nurse for follow up within established time frames

Utilization Management Job Description

Job Description Example
Our growing company is looking for an utilization management. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for utilization management
  • The LPN – Resource Utilization Technician (LRUT) gathers relevant information accurately and systematically
  • Reviews patient placement and documentation of patient needs for identified patient population(s)
  • Identified Interqual discrepancies are forwarded to physician reviewers in a timely manner to receive certification determination and/or physician‑to‑physician communication
  • Supervises attendance, behavior, vacation
  • Promoting and implementing operational goals and objectives
  • Maintaining workflows, buckets, mail boxes, inquiries, reports
  • Assisting other UM Supervisors as need arises
  • Meeting department turn around time
  • Fosters positive interaction and relationships with all internal departments and staff, external contacts and ensures department resolution of problems
  • Duration is TEMP-HIRE
Qualifications for utilization management
  • Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections Participates in departmental cost containment
  • Requires walking, sitting, and/or standing for long periods of time
  • Requires constant attention to detail, reading of medical records, and meeting deadlines
  • Generates approval and denial letters as directed by the Nurse Reviewer and Medical Director
  • Minimum of one year of experience in data entry and general office duties required
  • Minimum three (3) years of healthcare experience

Utilization Management Job Description

Job Description Example
Our growing company is hiring for an utilization management. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for utilization management
  • Utilizes established benchmarks to monitor, track, and trend aggregated, product specific and plan specific UM metrics
  • Supervise the daily operations of the UM staff
  • Ensure appropriate usage of resources in order to facilitate the UM process
  • Ensure compliance within applicable state program guidelines
  • Evaluate compliance policies and procedures and analyze/recommend enhancements
  • Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements
  • Identify opportunities for process improvements necessary to facilitate department functions
  • Educate staff as necessary to ensure consistent performance and adhere to standards
  • Assist UM Manager and Director with coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary
  • The ideal candidate will have a plan in place regarding the structure of their department
Qualifications for utilization management
  • Utilization Management/Quality Improvement experience
  • Ability to work across organization and tap into resources to accomplish goals and to problem solve
  • Minimum three (3) years of healthcare experience in managed care
  • Knowledge of governmental indemnity, No-Fault, Worker's Comp and Health Plan insurance coverages
  • Regulatory compliance as established by NCQA, HCFA
  • Utilization Management required

Utilization Management Job Description

Job Description Example
Our innovative and growing company is looking for an utilization management. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for utilization management
  • Under the general supervision of the Supervisor, Utilization Management, this position screens calls from members and providers providing information to members regarding the accessing of care and assisting providers in the authorization process
  • Screens information received and refers members to the appropriate provider and/or contacts the provider directly for members
  • Facilitates the authorization process for requests that do not require clinical criteria application or judgment
  • Provides relevant information to members and assists them in resolving Plan related problems when Member Services personnel are not available
  • Acts as a resource to staff for questions related to the prior authorization process
  • Refers unresolved prior authorization process questions to the Lead Intake Specialist
  • Assists the Lead Intake Specialist in identifying, planning and implementing staff training programs
  • Identifies and reports member and provider educational opportunities to the Lead Intake Specialist
  • Accurately answers questions regarding Plan benefits and Utilization Management requirements for members and providers
  • Makes appropriate inquiries to determine potential coordination of benefits and advises appropriate provider and claims staff of same
Qualifications for utilization management
  • Prefer combination of 2-3 years of varied clinical experience in a health care management environment, Hospice, outpatient
  • Motivate others to achieve desired outcomes through innovation, coaching and delegation
  • Experience with Microsoft Office Suite of products Ability to communicate ideas in verbal and written form
  • Extensive knowledge workload management for multiple systems and functions
  • Ability to multi-task and accept large work assignments
  • Consult and coordinate process improvement activities in order to gain efficiencies within the department

Utilization Management Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of utilization management. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for utilization management
  • Performs other related duties and projects as assigned within the assigned timeframes
  • Act as first level physician reviewer for all cases referred by the Quality Improvement and Care Management Departments
  • Actively participates in the daily utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns
  • Communicate and educate network providers regarding clinical guidelines, pathways, protocols, and standards related to quality and utilization processes
  • Daily interventions support implementation of the Health Plan's Quality Improvement and Care Management Programs
  • Interacts with physicians regarding opportunities to improve member satisfaction and compliance with Utilization Management and Quality Improvement policies and procedures
  • Keep current with accepted standards and professional developments in the areas of quality improvement and utilization management
  • Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan
  • Provide leadership and direction in meeting Quality Improvement and Care Management goals directed at improvements in member health status outcomes and established business strategies
  • Provide leadership direction for provider credentialing processes
Qualifications for utilization management
  • Coordinate and assist with any internal and external audit efforts
  • Must be comfortable working in a high volume, stressful, metrics driven environment
  • Medical benefits, patient care services, claims and/or insurance background preferred
  • Professional, detail oriented and accurate
  • Conduct telephonic concurrent review to determine medical/behavioral appropriateness of inpatient care/bed days
  • Discuss requests with treating physicians and other healthcare professionals to better understand plan of care

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