Utilization Review Manager in Cookeville, Tennessee at Cookeville Regional Medical Center

The Utilization Management Manager is responsible for overseeing the organization’s utilization review functions to ensure appropriate, cost-effective use of healthcare services. This role leads a team of UM professionals, drives compliance with regulatory and payer requirements, and partners cross-functionally to optimize patient outcomes, reduce denials, and improve overall revenue cycle performance.

Associates or Bachelor's Degree in Nursing Required

Current State of Tennessee Nursing Licensure

Strong knowledge of medical necessity criteria (e.g., InterQual or MCG) and payer requirements
Preferred experience with EMR systems (Epic strongly preferred) and data/reporting tools (e.g., Tableau, Power BI)
Ability to lead teams, manage workflows, and drive performance improvement
Knowledge of payer guidelines (commercial, Medicare, Medicaid) and regulatory requirements (CMS, state regulations)
Proficiency in Excel and reporting tools; ability to build dashboards and analyze large datasets
Strong written communication skills with experience drafting executive summaries
Deep understanding of utilization review methodologies and medical necessity criteria (e.g., InterQual, MCG) across inpatient, outpatient, and post-acute settings
Knowledge of payer contract terms, authorization requirements, and denial management strategies across commercial, Medicare, and Medicaid plans
Experience working with regulatory bodies and accreditation standards, including Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state-specific guidelines
Ability to reduce medical necessity and authorization-related denials through process redesign, staff education, and front-end integration
Experience leading or supporting appeals processes, including peer-to-peer reviews and clinical documentation improvement efforts
Ability to connect utilization performance to revenue cycle outcomes (e.g., DNFB, CFB, avoidable write-offs, LOS variance)
Responsible for building and monitoring KPIs, dashboards, and performance scorecards (e.g., LOS, denial rates, authorization turnaround times)
Hands-on responsibility with EMR and UM systems (e.g., Epic) including workflow optimization, reporting, and system enhancements
Ability to lead cross-functional initiatives spanning Case Management, Patient Access, Revenue Integrity, and Patient Financial Services (PFS)
Ability to influence physician behavior and drive alignment on documentation and level-of-care decisions
Developing policies, standard operating procedures (SOPs), and training programs for UM staff