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Director Utilization Management | RN

Linthicum Heights, MD

Director Utilization Management | RN

Job Description

Director, UM (RN) - Greater Baltimore

Amazing growth continues with this national firm - award winning programs of care and a chance to TRULY make a difference for the medically underserved population in Maryland

Benefits are excellent- career advancement opportunities are unlimited

Director will join an already successful team and have oversight for referral management, telephonic utilization review, prior authorization functions, and case management programs and ensuring compliance government and contractual guidelines.

  • Support and perform case management, disease management and on site concurrent review functions as necessary.
  • Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers.
  • Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements.
  • Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit.
  • Develop, implement and maintain policies and procedures regarding the prior authorization function.
  • Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
  • Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.


Job Requirements


  • Bachelor's degree in Nursing or equivalent experience. 
  • 5+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment.
  • 1+ years of utilization management and/or case management experience. 
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  • Current Maryland RN nursing license- or willing to obtain.

About MMS Group

MMS is a Managed Care executive search firm. We are Managed Care's complete recruiting resource.

Keywords: nurse manager, nurse executive role, nurse jobs near me, managed care jobs, leadership jobs in healthcare, nursing leadership and management jobs, utilization management job, utilization review jobs, anthem careers, humana careers

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