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)
Conducts clinical review on cases referred by case management staff and/or other health care professionals in accordance with the hospitals Utilization Review guidelines to ensure efficient utilization of health care services and to meet regulatory requirements. Meets with case management and health care team members to discuss selected cases and make recommendations for care. Interacts with medical staff members and medical directors of third party payers to discuss the needs of patients and alternative levels of care. Acts as consultant and resource to attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. Acts as consultant and resource to the medical staff regarding federal and state utilization and quality regulations. The physician advisor will act as a liaison between the Medical Documentation team (CDI), HIM, and the hospital’s medical staff to facilitate accurate and complete documentation.
Job Requirements: Required: Graduate of an accredited Family Medicine or Internal Medicine residency. Current New York State license to practice medicine. Preferred: Additional education in quality and utilization management through continuing medical education programs and self-study. Minimum of 5 years recent experience in clinical practice. Utilization management experience as a member of a UM committee or past physician advisor experience. Experience in documentation optimization, coding education and denials management preferred.
Monday-Friday
No Call Required
Base Pay: $250,000 based one experience
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