Utilization Review Manager

Utilization Management Dept.  
Full Time
Day Shift 

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina.

The 607-bed teaching hospital anchors a health care network that includes five community medical centers and employs more than 8,000 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina’s first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and nearly 80 physician practices.  Its postgraduate medical education programs include family medicine and transitional year.





Job Summary

Provides day to day leadership to the Utilization Review Specialists and department Administrative Assistants. Coordinates and directs all utilization review functions for inpatient admissions and patients placed in Observation. Serves as the department expert regarding issues related to patient classification and reimbursement. Trends and analyzes data to assist in determining opportunities for improvement.

Minimum Qualifications

Minimum Education: Bachelor’s Degree in Nursing
Minimum Years of Experience: 3 Years of experience in an acute care hospital setting
Substitutable Education & Experience: Consideration will be given to candidates holding an ADN or diploma degree who are currently enrolled in a BS in nursing or RN-MSN program with the expectation that the BS in nursing degree/coursework is completed within 12 months of hire/promotion to role.
Required Certifications/Licensure: Registered nurse currently licensed in the State of South Carolina;
National certification in Case Management or other related certification (national certification may be obtained within 12 months of hire/promotion into the role).
Required Training: Experience in utilization review/case management

Essential Functions

  • Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff.  Accepts chain of command, supervision, and constructive criticism.
  • Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
  • Contributes to teamwork and creates harmonious, effective and positive working relationships with others.
  • Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated.
  • Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected.
  • Exhibits telephone courtesy by:  Answering promptly with name and department; Speaking with pleasant tone while focusing on caller; Transferring calls correctly and promptly; Attending to calls on hold in a timely manner
  • Maintains confidentiality by:; Discouraging gossip; Using discretion when discussing patient, work, or LMC-related information with others.
  • Utilizes the service recovery process to resolve complaints (GIFT).
  • Embodies those behaviors, philosophies, and values which serve to uphold the ideals and enhance the image of Lexington Medical Center.
  • Models LMC philosophy, standards of care, standards of practice, policies, procedures and protocols.
  • Functions as professional role model for supervised staff.
  • Demonstrates receptiveness to change and flexibility in meeting department needs.
  • Maintains current knowledge base (attains 40 hours of educational hours annually).
  • Identifies staff educational needs and implements measures to address needs.
  • Actively involved in discussion of unusual/complex cases and provides direction to Utilization Review Specialist and other members of the health care team.
  • Promotes high standards of practice and holds staff and self accountable.
  • Calm, suportive approach when addressing conflict.
  • Coordinates admission and continued stay review processes for all payor types. Supports revenue integrity and compliance through established policies and procedures. Supports denial management and appeals.
  • Leads and directs the daily operations of the Utilization Review Specialists and Adminstrative Assistant staff.
  • Updates utilization review policies and procedures to maintain accuracy and compliance
  • Functions as a staff Utilization Review Specialist as needed.  Performs all duties within the role to included:   Performs admission and continued stay  reviews  utilizing InterQual criteria and applicable regulatory guidelines; Submits clinical data to third party payors and documents authorization; Refers Observation and Inpatient admissions lacking documentation of medical necessity to the Physician Advisor and completes all necessary follow through to ensure correct level of care and billing; Follows Condition Code 44 procedure when appropriate; Applies appropriate condition codes and modifiers to communicate accurate claims information; Documents denial information in electronic medical record.
  • Coordinates with other service areas as needed.
  • Supports good working relationships with other departments within the revenue cycle
  • Reviews denials and assists in the preparation of appeals as requested.
  • Actively supports participation of Utilization Review Specialists in throughput via the discharge planning process.
  • Provides oversight of the Medicare discharge expedited appeal process through the QIO 
  • Communicates effectively throughout the health care system.

Duties & Responsibilities

  • Stays current on changing regulatory requirements and provides education to  personnel
  • Acts as a resource person to the medical staff, physician practices, hospital departments, and other members of the health care team related to  utilization activities and related regulatory requirements.
  • Keeps Director, physicians and other health care team members informed of activities through oral and written communications.
  • Communicates with hospital employees, medical staff, patients, families, and other agencies in a precise, timely and effective manner.
  • Serves on various committees as assigned.
  • Efficiently uses electronic communication and other system supports for conveying information
  • Interacts with others in a manner which promotes effective problem solving and team management.
  • Responds to patient/family/physician concerns related to level of care.
  • Collaborates well with Physician Advisor.
  • Assesses human resource needs and plans and evaluates employee activities to ensure safe, effective and fiscally sound operations. Responsible for recruiting, hiring and retaining of qualified staff, ensuring competence through orientation and education.
  • Demonstrates ability to work with personnel in a manner that fosters positive employee development and performance.
  • Assists with the development and adherence of personnel budget.
  • Promotes an environment which provides opportunities for the continued professional development and broadened knowledge of staff.
  • Interviews and hires new employees and coordinates orientation processes for UR and administrative assistants.
  • Monitors and evaluates employee performance to include probationary, annual and disciplinary actions.
  • Participates in the development, implementation and evaluation of orientation programs for new employees.
  • Develops and maintains accurate and efficient schedule for staff.
  • Implements measures to assure productivity and effective use of human resources within the department
  • Works with Director on staffing changes.
  • Promotes and uses effective reward and recognition strategies
  • Provides leadership, counseling and support for staff.
  • Selects, uses, and accounts for material resources with appropriate consideration for patient/staff needs, hospital policies and procedures and budgetary constraints.
  • Collaborates with Director in the development of department capital and operating budgets and supports departmental operations within budgets.
  • Identifies opportunities for improvement and initiates and/or participates in development of action plans to achieve desired outcomes.
  • Collaborates with Director to develop departmental goals, objectives, and continuous quality improvement plans.
  • Develops and implements plan for department operations to support goals.
  • Monitors and reports progress toward goals at established intervals and adjusts activities/processes to improve compliance or success of initiative.
  • Participates in the identification of customer needs and expectations.
  • Uses available resources and appropriate administrative and organizational channels to facilitate the change process.
  • Positive change agent.
  • Performs all  other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

  • Day ONE medical, dental and life insurance benefits 
  • Health care and dependent care flexible spending accounts (FSAs)
  • Employees are eligible for enrollment into the 403(b) match plan day one.  LHI matches dollar for dollar up to 6%.
  • Employer paid life insurance – equal to 1x salary
  • Employee may elect supplemental life insurance with low cost premiums up to 3x salary 
  • Adoption assistance
  • LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
  • Tuition reimbursement
  • Student loan forgiveness

Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.

Nearest Major Market: Columbia
Nearest Secondary Market: South Carolina