Manger Utilization Management & Quality, Peace Hosptial

Primary Location:

Peace - Louisville

Address:

2020 Newburg Rd. Louisville, KY 40205

Shift:

First Shift (United States of America)

Job Description Summary:

About UofL Health:UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehabilitation Institute and Brown Cancer Center.With more than 12,000 team members—physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals—UofL Health is focused on one mission: delivering patient-centered care to each and every patient each and every day.

Job Description:

Position Summary and PurposeThe Manager of Utilization Management (UM) leads the strategic and operational oversight of utilization review and management across the academic healthcare system. This role ensures appropriate resource utilization, regulatory compliance, and alignment with clinical and financial goals. The Manager collaborates with medical staff, case management, revenue cycle, and IT to optimize care delivery and reimbursement.

Essential Functions:1.    Manage the day-to-day operations of the utilization review staff, including training, performance evaluation, and setting performance standards.  

2.    

Create, implement, and maintain policies and procedures for the UM program, ensuring they align with regulations and organizational goals

3.    

Analyze UM metrics, identify trends, and prepare reports for senior management or quality improvement committees to guide decision-making and demonstrate the impact of the program.  

4.    

Monitor the clinical review process to ensure patient care is appropriate, effective, and timely, and collaborate with physicians, case management and other professionals to improve utilization.

5.    

Identify opportunities to enhance the efficiency and accuracy of UM processes, often by working with physician advisors, case management, nursing leadership, and revenue cycle.   

6.    

Ensure the department complies with all applicable state and federal guidelines and manage audits from regulatory agencies or health plans. 

7.    

Provide mentorship, training and performance evaluations.

8.    

Ensure accurate documentation and data capture for billing and compliance.

9.    

Facilitate secondary reviews and appeals processes.

10.    

Performs other duties as assigned.Other Functions:

    Participate in UM system-wide UM committees and initiatives.Analyze utilization trends and recommend process improvements.

    Coordinate certified training programs (e.g., InterQual, MCG).Partner with IT to optimize UM-related systems (e.g., EMR, InterQual).

Additional Job Description:

Job Requirements(Education, Experience, Licensure and Certification)Education: Bachelor’s degree in nursing or related field, master’s degree preferred.

License: Active RN license or LCSW required to practice in the state of Kentucky. 

Certification: Case/Utilization Management (e.g., ACM, CCM, CMAC).

Experience: Minimum seven years of UM/Case Management experience in an acute care of academic health system. Minimum 4 years leadership experience. 

Job Competency:Knowledge, Skills, and Abilities critical to this role: 

    Strategic thinking Deep understanding of clinical workflows and regulatory requirements. 

    Strong communication and stakeholder engagement skills. Data-driven decision-making and continuous improvement mindset.UofL Health Core Expectation:At UofL Health, we expect all our employees to live the values of honesty, integrity and compassion and demonstrate these values in their interactions with others and as they deliver excellent patient care by:

    Honoring and caring for the dignity of all persons Ensuring the highest quality of care for those we serve

    Working together as a team to achieve our goalsImproving continuously by listening, and asking for and responding to feedback

    Seeking new and better ways to meet the needs of those we serve Using our resources wiselyUnderstanding how each of our roles contributes to the success of UofL Health