Director of Utilization

Overview

We are seeking a Director of Utilization Review to lead utilization management processes that support appropriate care delivery, regulatory compliance, and effective use of patient benefits. This role partners closely with clinical leadership and external reviewers to ensure timely reviews, optimize reimbursement, and maintain high standards of care across the facility.

 

​PURPOSE STATEMENT: 

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

Responsibilities

​ESSENTIAL FUNCTIONS: 

• ​Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.   
• ​Conducts and oversees 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.   
• ​Collaborates with physicians, therapist and nursing staff to provide optimal review based on patient needs.   
• ​Collaborates with ancillary services in order to prevent delays in services.   

• ​Evaluates the UM program for compliance with regulations, policies and procedures. 
• ​May review charts and make necessary recommendations to the physicians, regarding utilization review and specific managed care issues.   
• ​Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation. 

​OTHER FUNCTIONS:  

• ​Perform other functions and tasks as assigned. 

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

• ​Bachelor's Degree in nursing or other clinical field required. Master's Degree in clinical field preferred.  
• ​Six or more year's 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; or current clinical professional license or certification, as required, within the state where the facility provides services. 

 

 

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

 

AHCORP

#LI-SH1