Utilization Review Director at Summit BHC

, , United States -

Full Time

Start Date

Immediate

Expiry Date

17 Jan, 26

Salary

0.0

Posted On

19 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Clinical Experience, Insurance Verification, Medical Records Review, Team Leadership, Quality Assurance, Client Admission, Discharge Planning, Problem Solving, Communication, Regulatory Compliance, Data Analysis, Staff Supervision, Training, Performance Assessment, Collaboration

Industry

Hospitals and Health Care

Description

Utilization Review Director | Las Cruces Recovery Center | Las Cruces, New Mexico About the Job: PURPOSE STATEMENT: The Director of Utilization Management is responsible for the overall management of the UM department by leading and facilitating review of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria. Directs and manages the day-to-day operations and supervision of staff to obtain coverage for clients, monitors the progress of all UR cases and insurance appeals, problem solves when necessary and mitigates all issues with utilization. Monitors utilization of services and optimizes reimbursement for the facility while maximizing use of the client’s provider benefits for their needs. Roles and Responsibilities: ESSENTIAL FUNCTIONS: Assigns all clients to Utilization Review staff and supervises staff to ensure staff are completing insurance verifications on time and compliant with regulatory standards and requirements. Ensures staff are competent to review medical records of clients for appropriateness of level of care at admission and at intervals determined by documentation in medical record and to communicate client insurance status and needs with all disciplines. Leads a team of highly engaged members thru hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation. Works closely with Admissions Department to ensure client information is accurate and pre-certification is complete. Reviews application for client admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards. Manages any discrepancies regarding stated benefit information and insurance verification, need for updated benefits or follow-up on a problem with a pre-certification from admissions. Appeals all denials ensuring accuracy of information and effective coordination of correspondence. Analyzes client records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies. Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director. Analyzes insurance, governmental and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of clients. Compares client’s medical records to established criteria and confers with medical, clinical, nursing, and other professional staff to determine appropriateness of treatment and length of stay. Communicates and coordinates information with business office to recognize and resolve potential payment issues. Conducts and oversees concurrent and retrospective reviews for all clients. Assists review committee in planning and holding mandated quality assurance reviews. Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process. EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred. Four or more year's clinical experience in a substance abuse setting required. Four or more years’ experience in medical/psychiatric utilization management required. Comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria. Ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations and business office, providing needed information in a logical, concise manner using technical language that accurately describes client’s condition. LICENSES/DESIGNATIONS/CERTIFICATIONS: Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services. CPR and de-escalation certification required (training available upon hire and offered by facility). First aid may be required based on state or facility requirements. SUPERVISORY REQUIREMENTS: Minimum of three years supervisory experience in clinical setting/utilization required. Why Las Cruces Recovery Center?Las Cruces Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Las Cruces Recovery Center is an EOE. Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.

Responsibilities

The Director of Utilization Management oversees the UM department, managing admissions, continued stays, and discharge planning. They lead a team to ensure compliance with insurance and regulatory standards while optimizing client care and reimbursement.