DIR - UTILIZATION REVIEW / MGMT

About the Role

The Director of Utilization Review directs and oversees the Utilization Program for Inpatient and Outpatient services. This includes implementing case management scenarios, consulting with all services to ensure effective treatment plans for patients, overseeing responses to service requests, and interfacing with managed care organizations, external reviewers, and other payors.

Responsibilities

• Maintain confidentiality of sensitive and complex information.
• Supervise, direct, and evaluate the work performance of Utilization Review (UR) staff, including:
  • Completing continued stay reviews with external review agencies.
  • Maintaining Utilization Management files and logs in a neat, accurate, and orderly form.
  • Providing feedback to the clinical team regarding documentation, medical necessity criteria, and patients’ benefits.
  • Ensuring timely notification of denials and accurate MIDAS entries/reports.
  • Advocating on behalf of the patient and the hospital.
• Prioritize and coordinate daily Utilization Management (UM) workload, ensure appropriate staffing levels, and cover caseloads as needed.
• Complete continued stay reviews as needed.
• Review all cases for days that were not authorized to determine appeal options.
• Conduct routine chart audits or as indicated.
• Collaborate with the business office to coordinate the appeals process, write appeal letters, and process appeals in a timely manner.
• Provide documentation training to new and current employees as needed.
• Provide Utilization Management consultations to the UM department and other hospital departments as needed, including committee membership, audits, and reports.
• Chair the UM Committee and participate in meetings as required.
• Promote a positive work environment, encourage staff development, and provide timely recognition to enhance job satisfaction and retention.
• Perform other duties as assigned or required by this position.

This occupation may require handling human blood and other potentially infectious materials, which could result in exposure to bloodborne pathogens.

Requirements

• Master’s degree preferred; Bachelor’s degree required.
• State of Colorado licensure as LLP, LPC, LLPC, LMSW, LLMSW, or Registered Nurse.
• Basic Life Support (BLS) and CPR Certification (can be obtained at orientation).
• CPI Certification (can be obtained at orientation).
• Strong knowledge of crisis intervention, risk assessment, and behavior management.
• Knowledge of psychiatric symptomology, diagnosis, and basic chemical dependency.
• Strong knowledge of medical and psychiatric criteria for various levels of care.
• Ability to effectively communicate with diverse stakeholders, including patients, family members, coworkers, supervisors, and physicians.