The UM Lead is responsible for overseeing day-to-day activities within the Utilization Management (UM) department, including staffing, assignment management, and serving as the first line of escalation for problem-solving. This role ensures effective leadership and delegation of daily UM activities and workflows. The UM Lead is also responsible for intervening with payers to prevent denial escalation, managing in-house expedited appeals, and conducting medical reviews for post-claim audits. As a resource and mentor to the UM staff, the UM Lead provides education on payer requirements, regulations, and standard work practices. This role involves collaboration with the Director of Care Coordination/Case Management and a multidisciplinary team.

Essential Functions:

• Understands, incorporates, and demonstrates Trinity Health's Mission, Vision, and Values in all behaviors, practices, and decisions.
• Facilitates daily activities of the UM department and provides leadership to the team.
• Assists the Director in hiring, training, coaching, and evaluating personnel.
• Maintains confidentiality regarding personnel matters within the department.
• Works with healthcare providers to assess medical necessity and appropriateness of inpatient admissions, providing feedback on documentation to support these decisions.
• Collaborates with the team to maximize financial reimbursement for MercyOne Central Hospital through accurate and timely clinical documentation.
• Coordinates with the Pre-service Team to ensure pre-certification for patients with complex diagnoses or care settings, in accordance with payer requirements.
• Maintains strong relationships with insurance payers to facilitate authorization approvals.
• Collaborates with the Revenue Cycle, HIM, Denials, and Finance teams.
• Recognized as an expert in UM practices and technical skills.
• Demonstrates effective communication (verbal, written, and digital) in various forms including medical records, emails, and phone calls.
• Consults with other professionals to improve patient outcomes.
• Utilizes current literature to guide practices and improve outcomes.
• Seeks assistance in conflict resolution when needed.
• Effectively delegates tasks to other UM team members and evaluates their performance.
• Completes assigned learning materials and competency activities within orientation and beyond.
• Contributes to the professional growth of others by serving as a preceptor, coach, and mentor.
• Assists in managing resources to meet quality and financial goals.
• Performs other duties as assigned by the manager.
• Maintains knowledge of relevant federal, state, and local regulations, as well as Trinity Health’s Organizational Integrity Program, Standards of Conduct, and other policies to ensure adherence.

Minimum Qualifications:

• Comprehensive knowledge of Utilization Management, typically gained through a bachelor’s degree in Nursing, Healthcare Administration, or a related field, or equivalent relevant UM work experience.
• Previous leadership experience preferred.
• Current Registered Nurse License in the State of Iowa required.
• Certification in Utilization Management preferred.
• Comfortable working in a collaborative, shared leadership environment.
• Strong personal presence characterized by honesty, integrity, and a caring attitude, with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

Education:

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field.
• Relevant work experience in Utilization Management may be considered in lieu of degree.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.