Director of Utilization Review

Position Summary:

Oversees utilization management including, but not limited to: utilization review, case documentation, payer relationships, regulatory requirements, staff management and department administration. Supports the overall success of the hospital and promotes patient satisfaction, regulatory compliance and optimal reimbursement.

Minimum Qualifications:

Masters prepared healthcare leader/director (Nursing, Counseling, Psychology or Social Work).

Knowledge of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic codes with corresponding clinical assessment skills that support patient evaluation.

A minimum of 8-10 years of experience working in an acute inpatient psychiatric setting as a treatment team member or 5-7 years of experience in utilization management for both mental health and substance abuse behavioral health disorders.

Experience using data to identify trends. Ability to manage team productivity and compliance with required timelines.

Knowledge of managed care payer business practices, behavioral health hospital operations and medical necessity determinations.

Excellent oral and written communication skills that drive departmental hospital engagement.

Essential Requirements/ Job Specific Standards

Oversees all utilization management functions.

Oversees precertification, concurrent, and discharge utilization reviews.

Facilitates regulatory compliance by ensuring proper documentation and allocation of treatment resources.

Serves as a key member of the hospital management team. Acts as a key participant in hospital operations meetings that drive financial and clinical results.

Functions as a key liaison with all hospital physicians to align physician engagement with payer expectations, patient acuity and discharge planning requirements.

Leads payer engagement activities including post payment reviews, payer audit oversight and denial/appeal oversight.

Oversees the Utilization Management committee structure. Develops and monitors utilization management plans.

Directs utilization management staff and performs all administrative department head functions.