Utilization Management Director jobs in Gary, IN

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)

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Utilization Management Specialist II
  • Pinnacle Treatment Brand
  • Merrillville, IN FULL_TIME
  • Utilization Management Specialist

    Working onsite at our Merrillville, IN treatment facility

    *working collaboratively with the treatment team and health plans to obtain authorization for treatment

    We offer competitive salary, full benefits package, Paid Time Off, and opportunities for professional growth.

    Pinnacle Treatment Centers is a growing leader in addiction treatment services. We provide care across the nation touching the lives of more than 30,000 patients daily.

    Our mission is to remove all barriers to recovery and transform individuals, families, and communities with treatment that works.

    Our employees believe we are creating a better world where lives and communities are made whole again through comprehensive treatment.

    As a Utilization Management Specialist II, you will need to exhibit excellent communication and documentation skills and work closely with insurers, accrediting bodies, and other healthcare providers. Clinical expertise regarding patient level of care needs is provided to other staff in consultation to ensure proper care in the right amount, scope, and duration. This includes providing utilization review and management (including screening, referral, and information) for mental health and substance abuse services, as well as performing the identification, analysis, and resolution of resource utilization outliers consistent with established protocols, policies, and procedures. As a member of the Utilization Management Team, the Utilization Management Specialist II impacts the delivery of care at the system level through direct utilization management, feedback of performance data, training, and supported consultation. This position provides telephone triage support for the Admissions Department and reviews clinical and financial information to determine eligibility for the appropriate level of care for consumers.

    Requirements:

    • Master’s Degree in Social Work, Psychology, Counseling, or related Human Services field is required.
    • Licensed Clinical Social Worker (LCSW), Licensed Psychologist (LP), Licensed Professional Counselor (LPC), or Registered Nurse is required. Licensed Clinical Drug and Alcohol Counselor (LCADC) is preferred.
    • Minimum of five years’ experience in the mental health and substance abuse field required; experience with all target populations and direct experience performing benefits and/or utilization management in a managed care setting preferred.
    • Understand current DSM (Diagnostic and Statistical Manual) and ASAM (American Society of Addiction Medicine) Medical Necessity Criteria and demonstrate competence in making mental health and chemical dependency provisional diagnoses and level of care recommendations with available information.
    • Understand mental health and chemical dependency inpatient, partial hospital, intensive outpatient program (IOP) and outpatient modalities based on an assessment and medical necessity criteria.
    • Can relate and discuss benefits, medical necessity, and clinical information with provider network.
    • Knowledge and background with managed care and insurance.
    • Must possess a current valid driver’s license in good standing in state of employment and be insurable by the designated carrier. This role is required to drive for company purposes.
      • Travel up to 10% may be required to conduct site visits, attend meetings and conferences.

    Responsibilities:

    • Maintain prominent level knowledge of behavioral health utilization management criteria and best practices including coordination of care with insurance companies, Medicaid, and other payor sources. Provides, analyzes, and documents collaboration with stakeholders to ensure the consumer receives the most appropriate level of care as designated by medical necessity criteria. Records and analyzes Utilization Management Outcomes to identify trends in stakeholder response to the consumer’s needs.
    • Familiarity with current provider manuals by insurer. Provides information to the treating provider(s) regarding insurance plan specifications of the treatment of substance abuse and mental health.
    • Recommend new models and innovative practices to improve UM functions and cross-collaborative service efficiencies and effectiveness.
    • Model behavior and initiatives consistent with the Pinnacle Treatment Centers mission, vision and values and board focus areas.
    • Identify statistical, programmatic, and clinical outliers utilizing the outlier management database and established agency protocols. Analyze the outlier data, prioritize the data for further analysis and review, and collect sufficient data to complete the consultation process with each affiliate in a manner that seeks to build collaborative relationships with each provider. Analyze the outlier data to identify opportunities for regional development and performance improvement. Fully document all data collected and all analyses conducted during the review process. Develop action plans jointly with relevant providers to address the outliers when required, based on established agency protocols. Provide or arrange onsite reviews/consultation for unresolved outlier management issues and provide final recommendations based on the site review outcome.
    • Provide utilization data for performance improvement and regional development purposes.
    • Identify quality concerns related to programs, specific practitioners, or consumers, and notify the provider and relevant oversight committees (if relevant) of them.
    • Review behavioral health companies updated clinical information on a timely basis for the purpose of utilization management certification, continued stay, and transition of care.
    • Perform daily utilization management functions at designated Recovery Works/Pinnacle location(s) and take appropriate action when necessary. Close communication with the facility treatment teams and accountability to inform leadership of any issues pertaining to complete, accurate, timely documentation.
    • Process appeals with managed care companies. Ensure documentation submitted is complete, accurate, and timely.
    • Participate in multidisciplinary team and Flash meetings for current clinical status and to maintain consistency in documented issues in the Electronic Medical Record.
    • Assist in case management and transition of care duties as assigned.
    • Maintains tracking mechanisms including database administration and file administration for recordkeeping and information retrieval as directed.
    • Provides administrative and clerical support to designated Clinical, Medical, and Revenue Cycle Management departments.
    • Prepares presentations, special reports, correspondence, and documentation of meetings.
    • Utilizes clinical supervision and consultation appropriately to ensure work within scope of practice.
    • Maintains the confidentiality of consumer and other information.
    • Other duties as assigned.

    Benefits:

    • 18 days PTO (Paid Time Off)
    • 401k with company match
    • Company sponsored ongoing training and certification opportunities.
    • Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
    • Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)
    • Discounted tuition and scholarships through Capella University 

    Join our team. Join our mission.  

     

     

     

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Utilization Management Specialist II
  • Pinnacle Treatment Centers
  • Merrillville, IN FULL_TIME
  • Utilization Management Specialist Working onsite at our Merrillville, IN treatment facility working collaboratively with the treatment team and health plans to obtain authorization for treatment We of...
  • Just Posted

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Director of Clinical Management
  • Mendota Health
  • Gary, IN FULL_TIME
  • THIS IS A HYBRID POSITION. TRAVEL IS REQUIRED. Mendota Health is a leading provider of mobile wound care services. We specialize in helping patients heal their wounds by providing the best possible tr...
  • 1 Month Ago

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Director, Health Information Management
  • Porter-Starke Services
  • Valparaiso, IN FULL_TIME
  • POSITION SUMMARY Responsible for coordinating health information management (HIM) services across the multi-facility integrated healthcare system, which includes CMHC (Community Mental Health Center) ...
  • 28 Days Ago

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Director of Nursing
  • Infinity Healthcare Management
  • Hobart, IN FULL_TIME
  • NOW HIRING -- DIRECTOR OF NURSING (DON) *PayActiv* A comprehensive benefit package includes: Excellent Pay Tuition Reimbursement Flexible Scheduling Paid Birthdays Paid Vacation Time-Cash Out Option P...
  • 1 Day Ago

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Housekeeping/Laundry Director
  • Sterling Healthcare Management
  • Gary, IN FULL_TIME
  • ***Come be a part of something different – Excellent culture with competitive pay and Benefits - Join the Sterling Healthcare team! *** We are actively seeking a dedicated Housekeeping/Laundry Directo...
  • 1 Day Ago

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0 Utilization Management Director jobs found in Gary, IN area

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Director, Category Management
  • The Judge Group
  • Chicago, IL
  • Shearer's is a leading contract manufacturer and private label supplier in the snack industry in North America. Headquar...
  • 3/28/2024 12:00:00 AM

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Associate Director, Project Management
  • Initiative
  • Chicago, IL
  • Business Overview We believe in the power of media to reshape our industry and orchestrate a brand’s entire consumer exp...
  • 3/27/2024 12:00:00 AM

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Spa Director
  • Purple Eagle Spas
  • Chicago, IL
  • Job Description Job Description Are you looking for an opportunity for a career with significant growth potential? Are y...
  • 3/27/2024 12:00:00 AM

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Associate Director
  • Transamerica Premier Life Insurance Company
  • Chicago, IL
  • The Associate Director is responsible for developing new quality sales, conserving existing business, providing ongoing ...
  • 3/27/2024 12:00:00 AM

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Managing Director, Sales & Solutions - North American Utilities
  • CBRE
  • Chicago, IL
  • Managing Director, Sales & Solutions - North American Utilities Job ID 126039 Posted 11-Aug-2023 Service line GWS Segmen...
  • 3/26/2024 12:00:00 AM

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Director Quality Management
  • Kindred Healthcare
  • Melrose Park, IL
  • What makes Kindred Healthcare a great place to work? Our people, of course! Our clinicians answer this special calling b...
  • 3/25/2024 12:00:00 AM

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Managing Director
  • Selby Jennings
  • Chicago, IL
  • Join a dynamic and growing team at our Client; A premier financial services firm specializing in middle-market transacti...
  • 3/24/2024 12:00:00 AM

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Managing Director, Communication
  • Big Shoulders Fund
  • Chicago, IL
  • BIG SHOULDERS FUND Big Shoulders Fund is an independent tax-exempt charitable organization that provides support to scho...
  • 3/24/2024 12:00:00 AM

Gary is a city in Lake County, Indiana, United States, 25 miles (40 km) from downtown Chicago, Illinois. Gary is adjacent to the Indiana Dunes National Park and borders southern Lake Michigan. Gary was named after lawyer Elbert Henry Gary, who was the founding chairman of the United States Steel Corporation. The city is known for its large steel mills, and as the birthplace of the Jackson 5 music group. The population of Gary was 80,294 at the 2010 census, making it the ninth-largest city in the state of Indiana. It was a prosperous city from the 1920s through the mid-1960s due to its booming ...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Management Director jobs
$126,232 to $170,688
Gary, Indiana area prices
were up 1.3% from a year ago

Utilization Management Director in Johnstown, PA
Prior authorization decisions are also made using Medical Management and Behavioral Health Care Management internally derived policies and procedures developed using evidence-based guidelines based on national, state and locally established standards of practice.
March 01, 2020
Utilization Management Director in Carson City, NV
The utilization management coordinator must have strong project management skills to implement various programs within the allocated budget and set time limits.
January 31, 2020
Utilization Management Director in Melbourne, FL
Develops and administers polices and procedures for utilization control of inpatient and outside referral services countywide and for in a variety of categorical programs including the Medically Indigent Adult (MIA) Program.
January 08, 2020