DIR - UTILIZATION REVIEW / MGMT

Responsibilities

Position Summary:

The Director of Utilization Review is responsible for directing and overseeing the Utilization Program for Inpatient and Outpatient services. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payors.

Qualifications

Masters Degree Preferred, Bachlors Degree Requied. State of Colorado licensure as LLP, LPC, LLPC LMSW, LLMSW, or Registered Nurse
Basic Life Support and CPR Certification, can be obtained at orientation. CPI Certification, can be obtained at orientation.

Strong knowledge of crisis intervention, risk assessment, and behavior management. 5. Maintain confidentiality of sensitive and complex information.
Knowledge of psychiatric symptomology and diagnosis, and basic chemical dependency. 6. Strong knowledge of medical and psychiatric criteria for various levels of care.
The ability to effectively communicate to a variety of stakeholders including patients, family members, co-workers, Department Supervisors, Physicians, etc.

Supervises, Directs, and evaluates the work performance of UR staff, whose duties include: Complete continued stay reviews with external review agencies as indicated, Maintain Utilization Management files and logs in a neat, accurate and orderly form, Provides feedback to clinical team regarding documentation, medical necessity criteria and patients’ benefits, Provides timely notification of denials and accurate MIDAS entries/reports, Advocates on behalf of the patient and the hospital.
Prioritizes and coordinates daily UM workload, ensures appropriate staffing levels, and covers caseloads of staff as needed.
Completes continued stay reviews as needed.
Reviews all cases for days that were not authorized to determine appeal options.
Conducts routine chart audits or as indicated.
Collaborates with the business office to coordinate the appeals process, writes appeal letters and processes appeals in a timely manner.
Provides documentation training to all new employees and current employees on an as needed basis.
Provides Utilization Management consultations to UM department and other hospital departments as needed. Including committee membership, audits and reports as requested.
Chairs the UM Committee and participates in meetings as needed and required.
Promotes a positive work environment, encourages staff development, provides timely and meaningful recognition that promotes job satisfaction and retention.
Performs other duties as assigned/required by this position.

Occupation that requires, or may require, employees to handle human blood and other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.

 Equal Employment Opportunity
It is the policy of the facility to provide equal opportunity in employment to all employees and applicants for employment. No person will be discriminated against in employment based on race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state, or local laws.

 Americans with Disabilities Act
Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

 Service Excellence.
Service excellence is a part of all we do. Our standards include:
 Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.
 Demonstrate professionalism and excellence by looking professional, being accountable for actions and delivering excellence in our everyday work.
 Practice teamwork by participating in decision making and process improvement, communicating effectively and focusing on the problem/issue, not the person.

Masters Degree Preferred, Bachlors Degree Requied. State of Colorado licensure as LLP, LPC, LLPC LMSW, LLMSW, or Registered Nurse
Basic Life Support and CPR Certification, can be obtained at orientation. CPI Certification, can be obtained at orientation.

Strong knowledge of crisis intervention, risk assessment, and behavior management. 5. Maintain confidentiality of sensitive and complex information.
Knowledge of psychiatric symptomology and diagnosis, and basic chemical dependency. 6. Strong knowledge of medical and psychiatric criteria for various levels of care.
The ability to effectively communicate to a variety of stakeholders including patients, family members, co-workers, Department Supervisors, Physicians, etc.

Supervises, Directs, and evaluates the work performance of UR staff, whose duties include: Complete continued stay reviews with external review agencies as indicated, Maintain Utilization Management files and logs in a neat, accurate and orderly form, Provides feedback to clinical team regarding documentation, medical necessity criteria and patients’ benefits, Provides timely notification of denials and accurate MIDAS entries/reports, Advocates on behalf of the patient and the hospital.
Prioritizes and coordinates daily UM workload, ensures appropriate staffing levels, and covers caseloads of staff as needed.
Completes continued stay reviews as needed.
Reviews all cases for days that were not authorized to determine appeal options.
Conducts routine chart audits or as indicated.
Collaborates with the business office to coordinate the appeals process, writes appeal letters and processes appeals in a timely manner.
Provides documentation training to all new employees and current employees on an as needed basis.
Provides Utilization Management consultations to UM department and other hospital departments as needed. Including committee membership, audits and reports as requested.
Chairs the UM Committee and participates in meetings as needed and required.
Promotes a positive work environment, encourages staff development, provides timely and meaningful recognition that promotes job satisfaction and retention.
Performs other duties as assigned/required by this position.

Occupation that requires, or may require, employees to handle human blood and other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.

 Equal Employment Opportunity
It is the policy of the facility to provide equal opportunity in employment to all employees and applicants for employment. No person will be discriminated against in employment based on race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state, or local laws.

 Americans with Disabilities Act
Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.

 Service Excellence.
Service excellence is a part of all we do. Our standards include:
 Treat everyone as a guest by making a good first impression, anticipating needs and displaying service recovery skills.
 Demonstrate professionalism and excellence by looking professional, being accountable for actions and delivering excellence in our everyday work.
 Practice teamwork by participating in decision making and process improvement, communicating effectively and focusing on the problem/issue, not the person.

Position Summary:

The Director of Utilization Review is responsible for directing and overseeing the Utilization Program for Inpatient and Outpatient services. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payors.