Director of Utilization Review

Job Description

Job Description

The Director of Utilization Review provides strategic leadership and oversight of utilization management activities, including utilization management, cost containment, daily department operations, delegation oversight, and clinical program initiatives. The Director develops and manages daily operations, focusing on improving clinical and financial outcomes. He/she motivates others to balance patient needs and business process. Responsible for developing strategy to drive continual business growth built on a foundation of exceptional clinical care and quality provided to our patients.

Essential Job Duties:

• Leads and directs the utilization review function for treatment facilities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or services. Engages in peer to peer conversations to guide and support deliver of evidence-based care.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Manages treatment facility audits of operational process, patient care plan and medication documentation.
• Determines policies and procedures that incorporate best practices and ensure effective utilization reviews.
• Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies and procedures to continuously enrich care coordination efforts and ensure evidenced-based processes are utilized.
• Provides analysis and reports of significant utilization trends, patterns, and impacts.
• Consults with physicians and other professionals to develop improved utilization of effective and appropriate services.
• Facilitates planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Participates in telephonic outreach for collaboration with treating providers.
• This will include discussion of evidence - based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expenses.
• Assures continuous compliance regulatory and accreditation agency standards and requirements.
• Work with leadership to develop, direct and implement best practices for utilization review.
• Sets priorities and goals ensuring utilization performance, compliance and quality standards are met.
• Takes ownership for accreditation standards and deliverables for utilization management.
• Performs related duties, as requested.
• Upholds the Organization's ethics and customer service standards.

This job description is not intended to be all-inclusive. Employee may perform other related duties to meet the ongoing needs of the hospital.

Requirements

• Education: Masters degree in a healthcare related field preferred. High School degree or equivalent required.
• Experience: Experience in utilization review management preferred. Experience in UR, hospital finance, insurance or related experience required.
• License/Certification: None
• Knowledge, Skills & Abilities:
  • Knowledge of psychiatric service delivery system and treatment methods, with specific knowledge and skills in areas of risk management, infection control, and utilization review; strong oral and written communication skills, current knowledge of continuous Quality Improvement methodology; organizational and time management skills; skills in data collection, analysis, evaluation and interpretation; knowledge of applicable standards and regulations; problem solving skills; teaching or training skills.

• Must have advanced PC skills that include a combination of working in a Windows Operating System and Microsoft Outlook, Word and Excel and the ability to type a minimum of 30 words per minute.
• Must have excellent written and verbal communication skills.
• Must be able to analyze data and information quickly and thoroughly.
• Must be able to multi-task, prioritize with strong time management skills.
• Knowledge of applicable federal and state regulatory requirements.
• Ensures that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs.
• Assures regular production of management, monitoring, and reporting.
• Directs and implements collaborative ongoing performance improvement activities to achieve desired goals when necessary.

Screening: Must successfully pass background check, drug screen, physical and be able to provide positive employment references.

Physical Demands: With or without reasonable accommodations, must be able to stoop, kneel, crouch, reach, stand for sustained period of time, walk, pull, lift, raise and move objects from position to position (up to 50 lbs), finger grasp; feel sizes, shapes, temperatures, and textures; express or exchange ideas orally and potentially loudly, accurately, or quickly; visually detect, determine, perceive, identify, recognize, judge, observe, inspect, assess; perceive the nature of sound with or without correction; perform repetitive motions of the wrist, hands, or fingers.

If you are among the most competitive and qualified candidates for the job, you will be contacted directly by one of our hiring managers. Due to the high volume of applications we receive, we are unable to respond to individual inquiries regarding your application status. Good Luck & we hope to meet you soon!

Dallas Behavioral Healthcare Hospital is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.

Benefits

Full-time employees are eligible for medical, dental, vision, company paid disability, 401(k) and a generous amount of paid time off and more.