PURPOSE STATEMENT:

Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs. Direct and manage the day-to-day operations of the Utlization and Review department 

ESSENTIAL FUNCTIONS:

• Provide consultation and guidance regarding admissions and patient length of stay to a variety of payers.
• Secure authorizations with insurance companies for inpatient treatment and continue to obtain authorizations for duration of patient stay.
• Evaluate the utilization program for compliance with regulations, policies and procedures.
• Review clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.
• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

• · 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.

• Reports to and work directly with Sr. Director of Business Operations 

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

LI-MLRC

MIRLK

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.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility requirements.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.