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RN Manager Integrated Health Management
Department | Integrated Health Management |
Reports to | Director of Integrated Health Management |
Direct reports | Integrated Health Management Supervisor, Utilization Review RNs, RN Case Managers, and Care Navigators |
Classification | Full-time, salaried, exempt |
Work arrangement | On-site, Monday through Friday |
Position Summary
The RN Manager of Integrated Health Management manages thedaily clinical and administrative operations of Utilization Review, CaseManagement, and Care Navigation for a third-party administrator servingself-funded health plans. Reporting directly to the Director, the Managertranslates departmental priorities and approved policies into effectiveworkflows, supervises department personnel, monitors performance, resolvesoperational issues, and ensures timely, consistent service to members, employergroups, providers, brokers, vendors, and internal partners.
The Manager also maintains an active clinical role bycompleting utilization reviews as workload and departmental needs require. Theposition exercises independent judgment within established policies, plandocuments, regulatory requirements, clinical criteria, and delegated authority.Policy creation and approval remain under the Director and other designatedorganizational authorities.
Reporting and Supervisory Relationships
• Reports directly to the Director of Integrated Health Management.
• Directly supervises the Integrated Health Management Supervisor, Utilization Review RNs, RN Case Managers, and Care Navigators.
• Uses the Supervisor to support daily coordination, staff coverage, workflow monitoring, coaching, chart review, and escalation management while     retaining overall accountability for departmental operations and personnel performance.
• Provides the Director with timely updates regarding significant clinical, operational, compliance, staffing, vendor, employer-group, and stop-loss      matters.
Essential Duties and Responsibilities
Department Leadership and Staff Management
• Direct daily operations across Utilization Review, Case Management, and Care Navigation and coordinate priorities among the three functions.
• Assign and redistribute work based on volume, urgency, staff availability, service requirements, and clinical risk.
• Establish daily and weekly priorities, monitor completion, and address backlogs, delays, documentation gaps, and coverage needs.
• Provide performance coaching, feedback, education, and corrective action in accordance with organizational policy and in coordination with          Human Resources and the Director when required.
• Participate in hiring, onboarding, competency assessment, training, performance evaluation, staff development, and retention efforts.
• Develop the Supervisor’s leadership skills and clarify responsibilities delegated to the Supervisor.
• Promote consistent communication and collaboration among clinical staff, operational teams, and organizational leadership.
Clinical Operations and Member Management
• Perform prospective, concurrent, and retrospective utilization review using applicable plan benefits, clinical criteria, regulatory requirements, and     internal procedures.
• Consult on complex, high-risk, high-cost, or clinically sensitive case-management matters and assist staff with barriers that require advanced        nursing judgment.
• Ensure timely identification, assessment, outreach, care planning, documentation, follow-up, and closure of case-management opportunities.
• Support care-navigation activities involving provider access, steerage, member education, appointment coordination, ancillary services, and         escalation to licensed clinical staff.
• Coordinate physician review, peer-to-peer activity, adverse determinations, appeals, transition-of-care needs, and urgent clinical escalations as       applicable.
• Maintain appropriate clinical boundaries and ensure that benefit determinations and clinical decisions are made by individuals with the required       authority and credentials.
Workflow and Operational Oversight
• Develop, implement, and revise operational workflows, forms, job aids, documentation standards, and staff instructions within approved policy.
• Identify process gaps and recommend policy changes to the Director; do not independently establish or approve departmental policy.
• Ensure consistent use of departmental systems, reports, clinical criteria, communication tools, and documentation platforms.
• Coordinate workload coverage for absences, urgent requests, high-volume periods, system interruptions, and after-hours escalations.
• Lead operational projects assigned by the Director and communicate implementation needs, risks, and results.
Quality Compliance and Performance
• Monitor departmental service standards, turnaround times, productivity, documentation timeliness, caseloads, outcomes, and key performance       indicators.
• Conduct or oversee chart audits, quality reviews, competency validation, corrective-action follow-up, and trend analysis.
• Support compliance with applicable federal and state requirements, ERISA plan requirements, utilization-review standards, privacy requirements,    contracts, plan documents, and internal policies.
• Escalate suspected compliance concerns, privacy or security incidents, critical quality findings, untimely determinations, and other material risks      to the Director promptly.
• Prepare accurate reports and summaries for the Director, executive leadership, committees, employer groups, brokers, stop-loss partners, and       other approved recipients.
• Support utilization-review committee activities, annual program evaluation, criteria governance, delegated-vendor oversight, and corrective-         action monitoring as assigned.
Vendor Employer Group and Internal Collaboration
• Resolve routine and escalated service issues involving vendors, employer groups, providers, brokers, pharmacy partners, networks, and internal     departments within delegated authority.
• Coordinate complex cases and high-cost matters with stop-loss partners and other authorized stakeholders while protecting confidential            information.
• Clarify operational requirements, follow up on outstanding items, and elevate contractual, policy, financial, reputational, or unresolved issues to      the Director.
• Represent Integrated Health Management in internal and external meetings as assigned and communicate decisions and action items to affected      staff.
Decision Authority
The RN Manager is authorized to make routine operational decisions within approved policies, procedures, budgets, contracts, plan documents, and departmental objectives, including:
• Daily staffing assignments, workload distribution, scheduling adjustments, and coverage decisions.
• Performance coaching and corrective action consistent with organizational policy and Human Resources requirements.
• Operational workflow design and revision that does not create or change policy.
• Routine vendor and employer-group issue resolution within established contractual and organizational authority.
• Clinical and administrative escalations that fall within the Manager’s licensure, role, and delegated authority.
The Manager must obtain the Director’s review or approval for new or revised policies, material changes in departmental scope, unbudgeted financial commitments, contractual changes, significant compliance matters, and issues that present substantial clinical, legal, financial, or reputational risk.
Requirements
Required Qualifications
• Active, unrestricted Registered Nurse license in Kansas.
• Bachelor of Science in Nursing from an accredited nursing program.
• At least five years of clinical nursing experience, preferably in medical-surgical nursing or a related setting that provides broad clinical knowledge.
• At least three years of healthcare management, supervision, or formal leadership experience.
• Demonstrated ability to supervise clinical and nonclinical staff, manage competing priorities, and address urgent or sensitive matters.
• Working knowledge of clinical documentation, medical terminology, levels of care, treatment settings, and interdisciplinary care coordination.
Preferred Qualifications
• Experience in utilization review, case management, care management, discharge planning, managed care, health-plan operations, or a third-       party administrator environment.
• Knowledge of self-funded health plans, ERISA plan administration, stop-loss reporting, prior authorization, appeals, provider networks, and         pharmacy-benefit coordination.
• Professional certification related to case management, utilization management, quality, or managed care.
Knowledge Skills and Abilities
• Strong clinical judgment and the ability to recognize urgent, complex, high-risk, and high-cost situations.
• Ability to interpret plan documents, clinical criteria, procedures, service standards, contracts, and regulatory requirements.
• Clear written and verbal communication with members, staff, providers, employer groups, vendors, and senior leaders.
• Sound judgment when handling confidential information, personnel matters, competing priorities, and escalated concerns.
• Ability to analyze operational and clinical data, identify trends, and use performance results to improve workflows and staff performance.
• Proficiency with standard office applications and the ability to learn claims, care-management, utilization-review, customer-service, and reporting     systems.
Schedule and Availability
• Full-time, on-site position with a regular 8:00 a.m. - 5:00 p.m., Monday-through-Friday schedule.
• Occasional evening or weekend work may be required to address urgent operational needs or deadlines.
• Serves as an after-hours escalation resource according to departmental coverage expectations.
Working Conditions and Physical Requirements
The position is performed primarily in a professional office environment and requires prolonged computer and telephone use, review of detailed clinical and administrative information, and frequent communication with internal and external contacts. The employee must be able to perform the essential functions of the position with or without reasonable accommodation.
Benefits
Medical insurance
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Dental insurance
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Vision insurance
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Employer-paid life insurance
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Employee Assistance Program (EAP)
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401K with 7% employer contribution
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Paid Time Off (PTO)
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Paid holidays
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Flexible Spending Account (FSA)
General Statement
This job description describes the primary responsibilities and qualifications of the position. It does not list every duty that may be assigned. Responsibilities may change based on business needs, regulatory requirements, contractual obligations, and the needs of the Integrated Health Management Department.
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