Overview

Direct and manage the day-to-day operations of the Utilization Review department. 

Responsibilities

​ESSENTIAL FUNCTIONS: 

• ​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. 

​OTHER FUNCTIONS:  

• ​Perform other functions and tasks as assigned. 

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

• ​Bachelor's Degree in nursing or other clinical field required. Master's Degree in clinical field preferred.  
• ​Six or more year's clinical experience with the population of the facility preferred. 
• ​Four or more years’ experience in utilization management required.    
• ​Three or more years of supervisory experience required. 

​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. 

 

 

AHCORP

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