Director of Utilization Review

About the Role

The Director of Utilization Review provides strategic leadership and oversight of utilization management activities, including utilization management, cost containment, daily department operations, delegation oversight, and clinical program initiatives. The Director develops and manages daily operations, focusing on improving clinical and financial outcomes, and motivates others to balance patient needs and business processes. Responsible for developing strategy to drive continual business growth built on a foundation of exceptional clinical care and quality provided to patients.

Responsibilities

• Leads and directs the utilization review function for treatment facilities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or services.
• Engages in peer‑to‑peer conversations to guide and support delivery of evidence‑based care.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Manages treatment facility audits of operational process, patient care plan and medication documentation.
• Determines policies and procedures that incorporate best practices and ensure effective utilization reviews.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies and procedures to continuously enrich care coordination efforts and ensure evidence‑based processes are utilized.
• Provides analysis and reports of significant utilization trends, patterns, and impacts.
• Consults with physicians and other professionals to develop improved utilization of effective and appropriate services.
• Facilitates planning and establishing goals and policies to improve quality and cost‑effectiveness of care and service for members.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Participates in telephonic outreach for collaboration with treating providers, including discussion of evidence‑based guidelines, opportunities to close clinical quality/service gaps, and care‑plan changes that can impact health‑care expenses.
• Assures continuous compliance with regulatory and accreditation agency standards and requirements.
• Works with leadership to develop, direct and implement best practices for utilization review.
• Sets priorities and goals ensuring utilization performance, compliance and quality standards are met.
• Takes ownership for accreditation standards and deliverables for utilization management.
• Performs related duties, as requested.
• Upholds the organization’s ethics and customer service standards.
• May perform other related duties to meet the ongoing needs of the hospital.

Requirements

• Education: Masters degree in a healthcare‑related field preferred; High School degree or equivalent required.
• Experience: Experience in utilization review management preferred; Experience in UR, hospital finance, insurance or related experience required.
• License/Certification: None.

Skills

• Knowledge of psychiatric service delivery system and treatment methods, with specific expertise in risk management, infection control, and utilization review.
• Strong oral and written communication skills.
• Current knowledge of continuous Quality Improvement methodology.
• Organizational and time‑management skills.
• Skills in data collection, analysis, evaluation and interpretation.
• Knowledge of applicable standards and regulations.
• Problem‑solving skills.
• Teaching or training skills.
• Advanced PC skills, including Windows OS, Microsoft Outlook, Word, Excel; typing minimum 30 wpm.
• Excellent written and verbal communication abilities.
• Ability to analyze data and information quickly and thoroughly.
• Ability to multi‑task, prioritize, and manage time effectively.
• Knowledge of applicable federal and state regulatory requirements.
• Ensures information is documented/identified to enable root‑cause analysis and improvement of clinical programs.
• Assures regular production of management, monitoring, and reporting.
• Directs and implements collaborative performance‑improvement activities to achieve desired goals.

Physical Demands & Screening

• Must be able to stoop, kneel, crouch, reach, stand for sustained periods, walk, pull, lift, raise and move objects up to 50 lb.
• Finger grasp; ability to feel sizes, shapes, temperatures, and textures.
• Oral expression of ideas, potentially loudly, accurately, or quickly.
• Visual detection, determination, perception, identification, recognition, judgment, observation, inspection, and assessment.
• Auditory perception with or without correction.
• Repetitive motions of the wrist, hands, or fingers.
• Must successfully pass a background check, drug screen, physical examination, and provide positive employment references.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Company‑paid disability
• 401(k) retirement plan
• Generous paid time off and additional benefits