Job Type
Full-time
Description
Job Title: Assistant Director, Utilization Review
Company: Nexus
Department: Utilization Review
FLSA Status: Exempt
Work Location: Onsite, Schertz, TX
Reports To: Director, Utilization Review
Job Summary
The Assistant Director, Utilization Review plays a pivotal role in partnering with the Director, Utilization Review to lead, supervise, and train the utilization review team. This position blends leadership with analytical expertise in the collection, aggregation, analysis, and reporting of complex production data to ensure operational excellence. The data will be used to drive smarter allocation of administrative nursing resources and fuel continuous improvement in review processes.
Essential Job Functions
• Works in partnership with the Director, Utilization Review to provide leadership, supervision, training, and direction for the Utilization Review Department, ensuring optimal workload distribution and team performance.
• Collaborates with the Director, Utilization Review to gather and analyze data for comprehensive, individual performance evaluations for each Utilization Review Nurse.
• Partners with the Director, Utilization Review to establish and monitor workflow processes and production goals. Including the collection, aggregation, analysis, and reporting of complex production metrics.
• Maintains up-to-date knowledge of regulatory changes and ensures timely communications of updates to Utilization Review Nurses.
• Works jointly with the Director, Utilization Review to develop strategies for nurse retention and incentive programs.
• Partners with the Director, Utilization Review to design and implement educational initiatives.
• Assists the Director, Utilization Review in case audits for nurses in training, offering direct guidance to promote quality standards and actionable insights for quality development.
• Collaborates with the Director, Utilization Review in distributing cases during training, providing equitable opportunities for exposure to different request categories, clients, and state guidelines and requirements.
• Collaborates with the Director, Utilization Review to support call coverage and address questions from nurses undergoing their initial four-week training period.
• Conducts intermittent utilization and quality reviews.
• Performs pre-authorization, concurrent, and retrospective reviews dealing with Medical Necessity from the Workers' Comp system, Group Health, Disability, etc. The review requires and includes evaluation of clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes.
• Perform a low to moderate amount of research on a case-by-case basis.
• Produce high-quality, professional reports with impeccable grammar and spelling.
• Dictates all report information.
• Communicate and coordinate successfully with team members and vendors in both spoken and written formats.
Requirements
• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence.
• Proficient in producing clear, accurate reports, formal correspondence, and training materials for diverse audiences, with the ability to convey information effectively to management, staff, and all other stakeholders.
• Proficiency in grammar, spelling, punctuation, and document formatting, with strong oral and written communication skills.
• Comprehension of medical/surgical modalities and imaging techniques.
• Ability to analyze clinical documentation in relation to medico-legal review.
• Ability to interpret and apply appropriate guidelines to medico-legal reviews.
• Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines.
• Extensive knowledge and understanding of Utilization Review.
• Independently identifies and defines potential or current issues, gathers and analyzes relevant data, establishes facts, draws valid conclusions, and applies sound judgment and discretion in decision-making.
Education and Experience
• BSN with 1-2 years' experience in a Managed Care setting.
• Experience with various state evidence-based medicine guidelines.
• Experience in a previous management role is preferred.
• Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook.
License and Certification
• Must hold a current and unrestricted RN license.
Driving Essential
• No
Position Demands
The physical demands described are representative of those that must be met by a team member to successfully perform the essential functions of the job and are as follows.
• Sit or stand to complete assigned work on a computer and with other standard office technology. An ergonomic workspace is provided for both options.
• Use hands and fingers to operate a keyboard, mouse, and other applicable office equipment.
• Communicate clearly and effectively in person, over the phone, and via email.
• Occasionally stand, walk, reach with hands and arms, and stoop or kneel as applicable.
• Occasionally lift and/or move up to 20 pounds as applicable.
• Specific vision abilities required include close vision, distance vision, and the ability to focus.
• The work environment is a typical office setting with low to moderate noise levels.
Reasonable accommodation may be made to enable individuals with disabilities to perform these functions.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All company team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.
