• Director of Utilization Review Management

    Job ID
    2018-1977
    # of Openings
    1
    Job Locations
    US-NJ-Lafayette
    Posted Date
    3 weeks ago(3 weeks ago)
    Category
    Clinical
  • Overview

    POSITION SUMMARY

     

    The Director of Utilization Management is responsible for the supervision, education, mentoring and enhancement of UR Team performance and day-to-day operations of the Utilization Management Department. The Director will contribute to AAC’s success by ensuring appropriate authorizations and extending length of stays based on use of medical necessity criteria, evidence-based medicine and collaboration with internal teams.

     

    EDUCATION, EXPERIENCE SKILLS & ABILITIES

     

    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    • Master’s degree in Nursing or Behavioral Health field
    • Unrestricted RN license
    • Five (5) years’ experience in direct utilization management services and;
    • Two (2) years’ experience in supervision of utilization management services.
    • Ability to read and interpret written information; write clearly and informatively; edits work for spelling and grammar. Ability to speak clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; and participates in meetings.
    • Good working knowledge of Microsoft Word, Excel, and Outlook.
    • Experience with ASAM criteria preferred.
    • Familiarity with health insurance, managed care organizations, and third-party payers..
    • Strong clinical skills
    • Knowledge of behavioral health resource management
    • Ability to prepare clinical reviews for managed care companies
    • Ability to ensure appropriate and necessary utilization of company resources
    • Ability to interact with healthcare professionals in all inpatient disciplines to assemble a clear, concise understanding of the patient's healthcare needs.
    • Ability to develop positive working relationships with managed care organizations.
    • Excellent customer service skills.
    • Ability to be continually proactive.
    • Strong negotiation skills.
    • Patient/institution advocacy skills.
    • Ability to maintain composure and dignity in all interactions and circumstances.
    • Strong attention to detail.
    • Strong communication skills.
    • Ability to work in a fast-paced, demanding environment with constant interruptions, and multitask.

    Reports To: Facility CEO

    Responsibilities

    Job Duties:

    • Complies with all performance measuring regarding precertification, concurrent reviews and appeals.
    • Maintains an accurate record of authorizations in company designated platforms in a timely manner.
    • Reviews all clinical documentation necessary for insurance authorization review.
    • Collects, reviews and analyzes utilization review information and participate in special utilization review projects.
    • Works cooperatively with clinical team members to obtain necessary clinical information.
    • Attends UR Meetings in person or via remote connection to discuss activities/needs of UR department.
    • Update UR census data with new admissions and level of care (LOC).
    • Send daily census data to clinical team and upload to Share Point for billing team. Follow-up with UR team on missing authorizations and new admits.
    • Update monthly dashboard with key metrics, such as, number of clients, LOC, billed days, and uncovered days.
    • Track each client’s LOC changes on a data sheet and submit to Facility CEO monthly.
    • Monthly, create a random list of charts from Accucare. Distribute to UR team in order to complete a quality assessment.
    • As needed, answer overflow calls from reception area and forward to the appropriate department/person.
    • Pre-certify insurance clients by completing reviews as needed with insurance companies to extend the stay of client in treatment; work with the clinical and client care team to communicate insurance case managers request for specific treatment, follow ups, and individualized care; communicate authorizations to clinical team; and prepare for weekly meetings to discuss appropriate discharge dates based on authorizations.
    • Maintains a partial caseload and provides coverage for staff absences
    • Oversees assignment of cases
    • Provides daily consultation and supervision as needed
    • Hires, Orients and Trains new staff
    • Approves PTO and leave requests
    • Completes 90-day and Annual Evaluations
    • Develops and maintains a system of appeals peer review, post service claims and reconsiderations including internal and external review escalation
    • Monitors, reports and recommends changes based on UR dashboard information
    • Conducts monthly UR meetings to discuss department and system issues
    • Work with other UR teams to develop consistency and provide for adoption of best practices
    • Participate in Corporate UM activities
    • Monitors adherence to company, corporate and department policies and procedures
    • Create and support a positive, professional and team-oriented environment
    • Other duties as assigned
    • Management ONLY Essential Job Duties and Responsibilities
    • (please mark N/A if not applicable)
    • Responsible and accountable for managing direct reports
    • Preparation and presentation of performance evaluations
    • Provides objective feedback to employees
    • Makes appropriate compensation recommendations, if applicable
    • Provides appropriate training for department and hold staff accountable for attending required training
    • Holds interviews for vacant positions and makes appropriately selects candidates to fill open positions
    • Responsible for recommending and ensuring regulatory staffing patterns & managing annual budget.
    • Monitors adherence to company and department policies, procedures and practices
    • Creates and supports a positive, professional, team-oriented, harassment free work environment by understanding and complying with the company’s policies
    • Other job duties – as assigned

    Qualifications

    Job Responsibilities:

    • Master's Degree in a behavioral health related field or RN (Registered Nurse),  credentials preferred.
      • Master’s Degree in a behavioral health related field and 2+ years experience in behavioral health and/or utilization management services. 
      • OR
      • Bachelor’s degree in a behavioral health related field 4+ years experience in behavioral health and/or utilization management services.
    • Two year’s medical billing experience.
    • Ability to read and interpret written information; write clearly and informatively; edits work for spelling and grammar.
    • Ability to speak clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; and participates in meetings.
    • Working knowledge of Microsoft Word, Excel, and Outlook.

    AAC is committed to principles of equal opportunities for all employees.  The Company will provide reasonable accommodations that are necessary to comply with State and Federal disability discrimination laws.

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