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)
Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies.
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Is responsible for managing all denials by conducting a comprehensive review of clinical documentation, clinical criteria/evidence-based guideline, policy, and or EOC/benefit policy.
2. Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.
3. Formulates a clear and concise clinically based or administrative argument to denial rationales supported by clinical criteria, including but not limited to, CMS, Florida Medicaid, CFR, Health Plan, InterQual (IQ), Milliman Care Guidelines (MCG), and UpToDate.
4. Complies with company and department policies and procedures to ensure timely and denials.
5. Follows Medicare/Medicaid’s denial rationale best practices.
6. Educates clinical and non-clinical staff within the guidelines of Leon Health’s policies and procedures and Medicare/Medicaid guidelines to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently.
7. Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization and concurrent denial reviews.
8. Is responsible for the data entry of denial decision communications to provider and members into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies.
9. Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate.
10. Collaborates with clinicians and/or providers to obtain necessary clinical documentation for medical reviews.
QUALIFICATIONS
WORK EXPERIENCE
LANGUAGE SKILLS
CERTIFICATES, LICENSES, REGISTRATIONS
Job Type: Full-time
Benefits:
Schedule:
Experience:
License/Certification:
Work Location: In person
0 Utilization Management Director jobs found in Miami, FL area