GENERAL SUMMARY: Responsible for the daily management in one or more of the various health services areas (Pre-authorization, Concurrent Review, Complex Case Management, Appeals, and/or Disease Case Management). Serves in an active managerial role to assist in the development, implementation, and evaluation of the utilization management process. ESSENTIAL RESPONSIBILITIES: - Provides management and direction to one or more health services areas (Pre-authorization, Concurrent Review, Complex Case Management, Appeals, and/or Disease Case Management); including, staffing, training, monitoring, and evaluating. - Reviews the timeliness, appropriateness, and medical necessity of the utilization processes performed by the staff. Prepare reports detailing the monitored activities. - Actively participates in the development, implementation, and oversight of the department’s activities; serves in an adjunct role for policy and procedure development and implementation. - Assists in the identification of issues which may adversely impact the attainment of department goals/initiatives (i.e., inpatient bed days per thousand, outpatient surgery utilization, etc.) - Collaborates with other departments to educate providers, vendors, and members regarding network providers/specialists benefits and utilization management policies and procedures. - Attends meetings with internal workgroups and external business parties. - Assists in the identification and triage of potential quality improvement issues. Responsible for assuring issues are reported to the Quality Improvement Department. - Responsible for compliance with State and Federal law regarding the handling of utilization management decisions and/or appeals. Ensures compliance with national accrediting body standards regarding utilization management decisions and/or grievances. - Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions. - Performs other duties as required. JOB SPECIFICATIONS: - Registered nurse with active license in good standing in the state where job duties are performed. - Bachelor’s degree or equivalent experience. - Previous (5-7 years) experience in utilization management. - Previous (3-5 years) clinical experience. - Previous (3-5 years) managerial experience. - Experience in program development preferred.