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Manager Optum Utilization Review Jobs in Tennessee

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Manager Optum Utilization Review information

What does a manager Optum Utilization Review do?

A Manager of Optum Utilization Review oversees a team responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They ensure that all reviews comply with regulatory standards, company policies, and clinical guidelines. Managers also collaborate with healthcare providers, monitor team performance, and help implement process improvements to optimize patient outcomes and resource use. Their role is vital in balancing quality patient care with cost-effective service delivery.

How does a manager Optum Utilization Review typically collaborate with clinical and non-clinical teams to ensure effective case management?

As a Manager in Optum Utilization Review, you will regularly coordinate with clinical teams such as nurses, physicians, and case managers to review patient cases for medical necessity and compliance with policies. You’ll also work closely with non-clinical staff, including data analysts and administrative professionals, to streamline workflows and support accurate documentation. Effective collaboration ensures timely decision-making, helps resolve escalated cases, and supports continuous quality improvement initiatives. This role often requires strong communication and leadership skills to align multidisciplinary teams and achieve organizational goals.

What are the key skills and qualifications needed to thrive as a manager Optum Utilization Review, and why are they important?

To thrive as a Manager, Optum Utilization Review, you need a background in healthcare management, clinical expertise (often as an RN or related field), and experience with utilization management processes. Familiarity with utilization review software, electronic health records (EHRs), and relevant certifications such as CCM (Certified Case Manager) or URAC accreditation is typically required. Strong leadership, analytical thinking, and effective communication skills help you guide teams and collaborate with providers and payers. These competencies are crucial for ensuring compliance, optimizing patient care, and achieving organizational goals in a complex healthcare environment.

What is the difference between Manager Optum Utilization Review vs Utilization Review Nurse?

AspectManager Optum Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications in case management or utilization reviewRegistered Nurse (RN) license, certifications in case management or utilization review
Work EnvironmentSupervises teams, manages review processes, collaborates with healthcare providersConducts patient reviews, assesses medical necessity, documents findings
Employer & Industry UsageCommon in health insurance companies, managed care organizations, healthcare providersPrimarily in hospitals, insurance companies, healthcare organizations

The main difference is that the Manager Optum Utilization Review oversees the review process and team management, while the Utilization Review Nurse focuses on conducting individual patient assessments and reviews. Both roles require nursing credentials and knowledge of healthcare policies, but the manager has additional responsibilities in leadership and process oversight.

What are the most commonly searched types of Optum Utilization Review jobs in Tennessee?

The most popular types of Optum Utilization Review jobs in Tennessee are:

What are popular job titles related to Manager Optum Utilization Review jobs in Tennessee?

For Manager Optum Utilization Review jobs in Tennessee, the most frequently searched job titles are:

What job categories do people searching Manager Optum Utilization Review jobs in Tennessee look for?

The top searched job categories for Manager Optum Utilization Review jobs in Tennessee are:

What cities in Tennessee are hiring for Manager Optum Utilization Review jobs?

Cities in Tennessee with the most Manager Optum Utilization Review job openings:

Manager Optum Utilization Review jobs near you

Utilization Specialist - Part Time

Ascension St. Thomas Behavioral Health Hospital

Nashville, TN • On-site

Part-time

Re-posted 7 days ago

Job description

Overview

PURPOSE STATEMENT: 

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.  

Responsibilities

ESSENTIAL FUNCTIONS: 

  • Act as liaison between managed care organizations and the facility professional clinical staff. 
  • Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements. 
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.  
  • Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. 
  • Conduct quality reviews for medical necessity and services provided.   
  • Facilitate peer review calls between facility and external organizations.  
  • Initiate and complete the formal appeal process for denied admissions or continued stay.  
  • Assist the admissions department with pre-certifications of care.  
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates. 

OTHER FUNCTIONS:  

  • Perform other functions and tasks as assigned. 
Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

  • Required Education: High school diploma or equivalent. 
  • Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field. 
  • Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred 

LICENSES/DESIGNATIONS/CERTIFICATIONS:  

  • Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services. 
  • CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.   
  • First aid may be required based on state or facility requirements. 

 

ADDITIONAL REGULATORY REQUIREMENTS: 

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances  (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate. 

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.

ASCST

Employment Type: PART_TIME

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