Director of Utilization Review

About the Role

Direct and manage the day-to-day operations of the Utilization Review department.

Responsibilities

• Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.
• Conduct and oversee concurrent and retrospective reviews for all patients.
• Act as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.
• Collaborate with physicians, therapists, and nursing staff to provide optimal review based on patient needs.
• Collaborate with ancillary services to prevent delays in services.
• Evaluate the Utilization Management (UM) program for compliance with regulations, policies, and procedures.
• Review charts and make necessary recommendations to physicians regarding utilization review and specific managed care issues.
• Provide staff management including hiring, development, training, performance management, and communication to ensure effective and efficient department operation.
• Perform other functions and tasks as assigned.

Requirements

• Bachelor's Degree in nursing or other clinical field required.
• Master's Degree in clinical field preferred.
• Six or more years of clinical experience with the population of the facility preferred.
• Four or more years’ experience in utilization management required.
• Three or more years of supervisory experience required.

Licenses / Designations / Certifications

• If applicable, current licensure as an LPN or RN within the state where the facility provides services.
• Current clinical professional license or certification, as required, within the state where the facility provides services.