The Director of Utilization Management is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for clients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the client's provider benefits for their needs.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.
Six or more year's clinical experience with the substance use disorder population required.
Four or more years' experience in medical/psychiatric utilization management required.
Minimum of three years supervisory experience in clinical setting/utilization required.
Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria.
Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client's condition.
LICENSES/DESIGNATIONS/CERTIFICATIONS: • CPR and de-escalation certification required (training available upon hire and offered by facility). • First aid may be required based on state or facility requirements.
ESSENTIAL FUNCTIONS: • Assigns all clients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements. • Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate client insurance status and needs with all disciplines. • Leads a team of highly engaged members thru hiring, orienting, performance assessment and
management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation. • Works closely with Admissions Department to ensure client information is accurate and pre-certification is complete. Reviews application for client admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards. • Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions. • Appeals all denials ensuring accuracy of information and effective coordination of correspondence. • Analyzes client records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director. • Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of clients. • Compares client's medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues. • Conducts and oversees concurrent and retrospective reviews for all clients. Assists review committee in planning and holding mandated quality assurance reviews. • Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process