Director - Utilization Management

 

GENERAL DESCRIPTION: Direct and manage the day-to-day operations of the Utilization Review department.

MINIMUM EDUCATION/EXPERIENCE/SKILLS:

Bachelor's Degree in clinical field or nursing, required. Master's Degree in clinical field preferred. Six or more year's clinical experience with the population of the facility, previous experience in utilization management preferred. Three or more years of supervisory experience required

 

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Current licensure  current clinical professional license or certification, as required, within the state where the facility provides, an LPN or RN within the state where the facility provides services; or

 

 

ESSENTIAL FUNCTIONS: Are determined by the facility and may Include, but are not limited to the following:

 

Monitor utilization of continuum services and optimize reimbursement for the facility while maximizing use of the patient's provider benefits for their needs. Responsible for the concurrent and retrospective review for all patients, Act as a liaison between Medicaid reviewers/gatekeepers and the staff completing required paperwork to facilitate the Utilization Review process, Work with physicians, therapist and nursing staff to provide optimal review based on patient Work with ancillary services in order to prevent delays in May review charts, make necessary recommendations to the physicians, In regard to utlllzation review and specific managed care issues. Supervises Um dept. staff Provide oversight and direction to utilization Demonstrates customer service behaviors when interacting with patients, team members and guests. Communicates patient  information  in  a  concise,  accurate,  timely,  and

confidential manner.

Utilizes available resources to assist with communication needs Ensures that accurate Information is communicated in a timely and effective manner throughout the hospital. Maintains a collaborative relationship with other

 

Professional Image and Behavior:

Adheres to the department hospital code Focuses on the needs of the patients and Avoids discussion of personal issues and/or complaints in the presence of the Assumes responsibility for behaviors and actions; accepts constructive criticism

in a positive manner.

Participates in opportunities to promote professional

 

 

 

OTHER FUNCTIONS:

 

Performs other functions and tasks as assigned/needed.

 

 

..

Communication:

Uses language that is .. easily understood and appropriate for the specific