Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Utilization Review Manager – Outpatient
LEORA is currently seeking a qualified Utilization Review Manager for a full time position at our new location in Columbus Ohio.
The primary responsibility of the utilization review manager is to collaborate with various insurance providers, including Medicaid, commercial and managed payers to complete concurrent reviews for approval of the outpatient program. Additional responsibilities include notifying payers of discharges and collaborating with discharge planners to determine appropriate length of stay and discharge plan. The utilization review manager will also coordinate peer reviews, monitor quality data related to denied days and look at potential process improvements, etc.
Other duties include reviewing medical records and preparing clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array illnesses, intensity of service, and care coordination needs are key, as the manager must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review manager works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings.
The utilization review manager manages all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the manager result in the overturning of denied claims and recovered revenue for the health care provider. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation.
Utilization Review Manager Tasks and Responsibilities:
Our employees enjoy competitive salaries and an excellent benefits package in a great team environment! If you meet the qualifications listed below, respond to this ad immediately with your resume for confidential consideration.
POSITION REQUIREMENTS
Job Type: Full-time
Salary: $54,000.00 - $60,000.00 per year
Benefits:
Medical specialties:
Physical setting:
Schedule:
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