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Manager Interqual Jobs in Kentucky (NOW HIRING)

Mission Hospital

RN Case Manager

Bowling Green, KY · On-site

Provides case management services for both inpatient and observation patients as assigned ... InterQual experience (preferred) Benefits TriStar Greenview Regional Hospital, offers a total ...

Prime Healthcare

$85 - $124/hr

Overview Director of Case Management RN or LCSWEmployment Status: Full-Time, Days, ExemptPay Range ... Knowledge of Milliman Criteria and InterQual Criteria preferred. Pay Transparency Olympia Fields ...

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Manager Interqual information

How does a Manager Interqual typically collaborate with clinical and administrative teams to ensure effective utilization review?

A Manager Interqual works closely with both clinical staff—such as physicians, nurses, and case managers—and administrative teams to implement and oversee the use of InterQual criteria in utilization review processes. They facilitate training, address questions about criteria application, and help resolve discrepancies between clinical recommendations and insurance requirements. Regular meetings and interdisciplinary rounds are common, ensuring that patient care decisions are well-documented and meet regulatory standards. This collaborative approach helps streamline approvals, reduce denials, and maintain high-quality patient care.

What is the difference between Manager Interqual vs Clinical Case Manager?

AspectManager InterqualClinical Case Manager
CredentialsTypically requires nursing or healthcare management certificationsRequires nursing or social work licensure and clinical experience
Work EnvironmentHealthcare organizations, utilization review departmentsHospitals, insurance companies, community health settings
Primary FocusUtilization management, policy implementation, and compliancePatient advocacy, care coordination, and discharge planning

The Manager Interqual primarily oversees utilization review processes and policy adherence within healthcare organizations, often requiring management experience and specific certifications. In contrast, the Clinical Case Manager focuses on direct patient care, coordinating services, and ensuring appropriate treatment. Both roles are vital in healthcare but serve different functions related to patient care and resource management.

What are the key skills and qualifications needed to thrive as a Manager Interqual, and why are they important?

To excel as a Manager Interqual, you need a solid background in healthcare management, clinical guidelines, and utilization review processes, typically supported by a nursing or clinical degree and relevant experience. Familiarity with InterQual criteria, case management software, and healthcare compliance systems is crucial. Strong leadership, analytical thinking, and effective communication are valuable soft skills for guiding teams and collaborating with diverse stakeholders. These competencies ensure proper application of clinical criteria, optimize resource utilization, and support quality patient care and regulatory compliance.

What is a Manager Interqual?

A Manager Interqual is a healthcare management professional responsible for overseeing the use and implementation of the InterQual criteria within a healthcare organization. InterQual is a set of evidence-based clinical decision support tools used to ensure appropriate hospital admissions, continued stays, and other medical services. The Manager Interqual leads teams that review cases for medical necessity, ensures compliance with regulatory requirements, and collaborates with clinical staff to optimize patient care and resource utilization. They also provide training on InterQual standards and help integrate these criteria into hospital processes.
Manager Interqual jobs near you

Manger Utilization Management & Quality, Peace Hosptial

UofL Health

Louisville, KY • On-site

Full-time

Posted 11 days ago

Job description

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 Purpose
The 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 goals
• Improving 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 wisely
• Understanding how each of our roles contributes to the success of UofL Health

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