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)
Primary Purpose of Position: The primary purpose of this position is to supervise the IDD team which evaluates medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by Partners Behavioral Healthcare Management.
Role and Responsibilities:
Knowledge, Skills and Abilities:
Education/Experience Required: A Degree in a Human Services field with clinical licensure and at least three (3) years of experience in I/DD services or a Registered Nurse with three (3) years of experience in I/DD services, including three (3) years Administrative Supervisory experience.
Education/Experience Preferred: A Master’s Degree in a Human Services field with clinical licensure and at least three (3) years of experience in I/DD services or a Registered Nurse with three (3) years of experience in I/DD. Previous experience in Utilization Management.
Licensure/Certification Requirements: Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina. Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LPC, LPA, LMFT. An Associate license does not meet the requirements. An employee may be dual licensed with one of the specialties listed here can also be licensed as an LCAS. NC DMA contract requirements does not allow for an LCAS to be a standalone license for working in UM.
Employee is responsible for complying with respective licensure board’s continuing education/training requirements to maintain an active license.
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