Manager Utilization Management

Manager Utilization Management Job Code: 20073 Position Summary Responsible for the daily operations of the Utilization Management department including utilization review, denials, appeals, and compliance with Federal and regulatory conditions of participation. Collaborates with Care Management, Social Services, Financial Services, Hospitalist program, and Physician Advisors to meet quality patient outcomes while controlling cost and resource utilization. Responsibilities • Promotes and mentors team knowledge through the continual advancement of skills necessary for their professional development • Leads performance improvement initiatives with key members of the organization for utilization processes, trends and regulatory requirements of utilization management • Responsible for strong collaboration of utilization of resources with the Kootenai Care Network, ambulatory clinics and post-acute facilities • Assures utilization management compliance of CMS regulations and Conditions of Participation • A certain degree of creativity and latitude is required • Performs other related duties as assigned • Familiar with standard concepts, practices, and procedures within the field • Relies on experience and judgment to plan and accomplish goals • Regular and predictable attendance is an essential job function • Competent to meet age specific needs of the unit assigned Requirements and Minimum Qualifications • Bachelor's degree required in Nursing (BSN), Health Administration, or a related field; Masters preferred • BSN must have current State of Idaho Registered Nurse or licensure pending as documented by temporary licensure OR current RN licensure from a state participating in the "multistate privilege to practice" compact with Idaho • Minimum 5 years' acute hospital experience as direct care clinical or case manager and 1 year experience in non-hospital based health care required • Minimum 5 years supervisor or management experience required • MCG certification required • ACM or CCM certification preferred • Demonstrated knowledge of laws or regulations pertaining to the utilization review, reimbursement programs, quality and financial outcomes of patient care processes and accreditation required • Previous experience in utilization management, case management, project implementation, insurance practices and regulatory compliance preferred • BLS required Working Conditions • Must be able to lift and move up to 25 lbs • Must be able to maintain a standing and/or sitting position • Typical equipment used in a clinical job • Must be able to stoop, crouch or bend

Created: 2026-03-14