The Director of Utilization Review (UR) in a behavioral health setting oversees the UR process, ensuring appropriate and cost-effective care while adhering to regulatory and accreditation standards. This role involves managing the UR team, developing, and implementing policies, and collaborating with clinical staff to ensure optimal patient outcomes. Overseas utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes. Directs activities related to medical review process while monitoring the timeliness and accuracy of utilization management data and reporting. Leads utilization management activities including design and implementation that integrates with quality management. Develops and maintains relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners.

REQUIREMENTS

• Lead the UR process for behavioral health services, ensuring compliance with regulatory standards (e.g., URAC, CMS, NCQA), clinical protocols, and organizational policies.
• Negotiate full authorization of days through the provision of timely concurrent information that includes patient status, treatment, and anticipated discharge
• Coordinates the appeal of clinically denied days with managed care organizations and monitor results
• Proactively identifies patients at risk for denied days and works with treatment teams to minimize appeal risk
• Collaboratively work with Business Office to identify and appeal denied days within designated contractual protocols
• Audits Medicare files by verifying initial medical necessity: certifications of all Medicare admissions, re-certifications of all Medicare inpatients as required.
• Audits Medicare files for inpatients and partial programs. Prepares analyses of these audits and presents these findings to the CEO and the Quality Management Committee.
• Manage the UR team, including hiring, training, development, and performance management.
• Ensure adherence to regulatory and accrediting agency requirements, maintain records for compliance, and provide oversight for quality control.
• Conduct and oversee admission, concurrent, and retrospective reviews to assess medical necessity and appropriateness of care.
• Develop, implement, and revise departmental policies, procedures, and the annual plan in conjunction with the Sr. Clinical Services Director and CEO.
• Communicate effectively with clinical departments, physicians, and other stakeholders to ensure timely and appropriate patient care.
• Analyze data to identify trends, improve service delivery, and develop quality improvement initiatives.
• Train UR staff and other clinical personnel on best practices, regulatory requirements, and documentation standards.
• Collaborates with Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care.
• Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
• Serve as the management liaison to the auditors.
• Represent the organization externally, as necessary.
• Upgrade and implement an appropriate system of policies, internal controls, standards, and procedures.
• Performs related duties consistent with the scope and intent of the position.
  This job description is not intended to be all-inclusive. Employee may perform other related duties to meet the ongoing needs of the hospital. Duties may be modified or changed with or without notice.

KNOWLEDGE SKILLS AND ABILITIES

• Relevant experience in utilization management, behavioral health, or a related clinical setting.
• Strong leadership, management, and communication skills.
• Knowledge of regulatory requirements, accreditation standards, and health insurance policies.
• Proficiency in data analysis and reporting.
• Experience with healthcare information systems.
• Word processing and computer experience required. Microsoft Office Suite experience (Word, Excel, Access) required
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking skills.
• Ability to solve mid-level problems with minimal supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
• Ability to develop and present training materials to an audience.
• Ability to successfully manage conflict, negotiating “win-win” solutions.
• Patient advocacy focus.

PHYSICAL REQUIREMENTS/ENVIRONMENTAL CONDITIONS

Perform the following with or without reasonable accommodations:

• Ability to stoop, kneel, crouch, crawl, reach, stand, walk, push, pull, lift, grasp, and be able to perceive the attributes of objects such as size, shape, temperature, and/or texture by touching with skin, particularly that of the fingertips.
• Ability to express and exchange ideas via spoken word during activities in which they must convey detail or important spoken instructions to others accurately, sometimes quickly and loudly.
• Hearing to perceive the nature of sound with no less than 40 db loss @ Hz, 1000 Hz, and 2000 Hz with or without correction; ability to perceive detailed information orally and make fine discriminations in sound.
• Perform repetitive motions with wrists, hands, and fingers. Individual must be able to exert up to 100 pounds of force occasionally and to be able to lift, carry, push, pull, or otherwise move objects.
• Work requires a minimum standard of visual acuity with or without correction that will enable people in the role to complete administrative and clerical tasks, as well as inspect and analyze.
• Must be able to work and concentrate amidst distractions such as noise, conversation and foot traffic; ability to handle interruptions often and be able to move from one task to another
• While worker may possibly be subjected to temperature changes, the worker is generally not substantially exposed to adverse environmental conditions as the work is predominantly inside.

Please refer the Job description for details