ESSENTIAL FUNCTIONS:
 Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the
patient’s provider benefits for their needs.
 Conducts and oversees concurrent and retrospective reviews for all patients.
 Act as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate
the Utilization Review process.
 Collaborates with physicians, therapist and nursing staff to provide optimal review based on patient
needs.
 Collaborates with ancillary services in order to prevent delays in services.
 Evaluates the UM program for compliance with regulations, policies and procedures.
 May review charts and make necessary recommendations to the physicians, regarding utilization review
and specific managed care issues.
 Provide staff management to including hiring, development, training, performance management and
communication to ensure effective and efficient department operation.
OTHER FUNCTIONS:
 Perform other functions and tasks as assigned.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
 Bachelor's degree in nursing or other clinical field required. Master's degree in clinical field preferred.
 Six or more year's clinical experience with the population of the facility preferred.
 Four or more years’ experience in utilization management required.
 Three or more years of supervisory experience required.
LICENSES/DESIGNATIONS/CERTIFICATIONS:
 If applicable, current licensure as an LPN or RN within the state where the facility provides services; or
current clinical professional license or certification, as required, within the state where the facility
provides services