DIR - UTILIZATION REVIEW / MGMT

Position Summary

The Director of Utilization Review is responsible for directing and overseeing the Utilization Program for Inpatient and Outpatient services. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payors.

Responsibilities

• Complete continued stay reviews with external review agencies as indicated, maintain Utilization Management files and logs in a neat, accurate and orderly form, provide feedback to clinical team regarding documentation, medical necessity criteria and patients’ benefits, provide timely notification of denials and accurate MIDAS entries/reports, advocate on behalf of the patient and the hospital.
• Prioritize and coordinate daily UM workload, ensure appropriate staffing levels, and cover caseloads of staff 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 all new employees and current employees on an as needed basis.
• Provide Utilization Management consultations to UM department and other hospital departments as needed, including committee membership, audits and reports as requested.
• Chair the UM Committee and participate in meetings as needed and required.
• Promote a positive work environment, encourage staff development, provide timely and meaningful recognition that promotes job satisfaction and retention.
• Perform other duties as assigned/required by this position.
• Occupation that requires, or may require, employees to handle human blood and other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.

Qualifications

Masters Degree Preferred, Bachlors Degree Requied. State of Colorado licensure as LLP, LPC, LLPC LMSW, LLMSW, or Registered Nurse

Basic Life Support 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. Maintain confidentiality of sensitive and complex information.

Knowledge of psychiatric symptomology and diagnosis, and basic chemical dependency. Strong knowledge of medical and psychiatric criteria for various levels of care.

The ability to effectively communicate to a variety of stakeholders including patients, family members, co-workers, Department Supervisors, Physicians, etc.

Equal Employment Opportunity

It is the policy of the facility to provide equal opportunity in employment to all employees and applicants for employment. No person will be discriminated against in employment based on race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state, or local laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

Service Excellence

Service excellence is a part of all we do. Our standards include:

• Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.
• Demonstrate professionalism and excellence by looking professional, being accountable for actions and delivering excellence in our everyday work.
• Practice teamwork by participating in decision making and process improvement, communicating effectively and focusing on the problem/issue, not the person.