DIRECTOR - UTILIZATION REVIEW

UHS • $100K — $120K *
San Juan, PR 00926In-Person
Healthcare
5 - 7 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Master's degree in social work, psychology, psychological counseling, mental health counseling, or psychiatric nursing.
  • Active, unrestricted license in relevant jurisdiction for social work, psychiatric nursing, counseling, or psychology.
  • Valid professional membership for social work and psychiatric nursing.
  • At least five years of experience in mental health, with three years in a leadership role in utilization review or mental health case management.
  • Proficient in Microsoft Office applications.
  • Fully bilingual.

Responsibilities

  • Lead daily operations of the Utilization Review Department and ensure compliance with clinical protocols.
  • Oversee utilization review procedures according to industry standards and regulations from agencies like URAC and CMS.
  • Conduct regular audits of utilization reviews and ensure effective documentation practices.
  • Supervise team performance and case analyses, responding to treatment requests based on clinical guidelines.
  • Train staff on best practices and updates in mental health treatment guidelines.
  • Analyze data to identify trends and opportunities for improvement in service delivery.
  • Serve as the primary liaison with insurance companies and regulatory bodies regarding utilization management processes.

Benefits

  • Ongoing training and development opportunities for staff.
  • Support from leadership to ensure compliance with regulations and quality standards.
  • Work in a collaborative environment across various departments.
  • Access to resources for professional growth and education.
  • Engagement in strategic initiatives aimed at improving mental health service delivery.
Full Job Description
Responsibilities

Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization reviews, organization determinations and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensure that denial and appeal letters are responded to in accordance with industry standards .

Responsibilities and essential duties:
  • Oversee Utilization Review Processes:
  • Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with clinical protocols, and organizational policies.
  • Keep abreast of any legal or regulatory changes that impact on the UR functions and operations to ensure timely implementation.
  • Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines.
  • Conduct regular audits of utilization reviews to ensure adherence to policies and procedures, documentation of cases in established tools, use of best practices, and ethical standards.
  • Available daily for case analysis, as required.
  • Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards.
  • Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services.
  • Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management.
  • Ensure Compliance and Quality Control
  • Provides assertive, effective, and consistent supervision to assure quality control and service excellence.
  • Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments.
  • Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation.
  • Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards.
  • Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets.
  • Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC.
  • Supervises the Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director.
  • Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care.
  • Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement.
  • Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others.
  • Responsible for conducting internal audits within UR Department.
  • Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs.
  • Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements.
  • Training and Development
  • Train UR staff and psychiatrists in the best practices, regulatory requirements, and documentation standards.
  • Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
  • Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees.
  • Encourages the staff attendance and participation to the educational activities.
  • Communication
  • Demonstrates effective communication skills and reports to the VP of Clinical Affairs.
  • Maintains open communication with peers and the staff.
  • Keeps the staff informed about changes or situations related to department processes.
  • Meet with staff on a regular basis, one on one, and conduct monthly meetings or as needed.
  • Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes.
  • Communicate with patients and families about treatment options and the rationale for service denials, when appropriate.
  • Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions.
  • Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system.
  • Works in collaboration with other departments of the organization.
  • Represents the organization in different activities and meetings.
  • Develop and Implement Policies
  • In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan.
  • Establish and update UR policies and procedures to optimize services and resource use.
  • Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments.
  • Effectively manages staff related matters in accordance with the rules, personnel policies and procedures.
  • Develops an annual vacation plan taking into consideration the service needs and the employees requests.
  • Keeps the specialization license and professional association membership ( colegiación ) effective as it corresponds to the specialization, if apply.
  • Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.


    • Qualifications

      • Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
      • Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling in the relevant jurisdiction.
      • Professional associating membership ( colegiación ): Valid membership for Social Work and Psychiatric Nursing
      • A minimum of five years' experience in the mental health field, working directly with patients or in clinical services supervision. Three or more years of experience in a leadership role specifically in the utilization review area or in mental health case management field .
      • Require knowledge in Microsoft Office
      • Fully Bilingual

    About UHS

    UHS Careers

    Joining UHS presents an unparalleled opportunity to become part of a leading team of healthcare professionals dedicated to making a difference. UHS, known for its commitment to innovation and leadership in the healthcare sector, offers a variety of job opportunities that cater to a diverse range of skills and experiences.

    Explore Job Opportunities

    UHS is actively hiring and offers a wide array of positions, from clinical roles to administrative support. Each position at UHS is designed to challenge team members while providing meaningful service to the community. Explore the current job openings and find a career path that suits professional aspirations and skills.

    Internship Programs

    UHS provides robust internship programs that offer hands-on experience in the healthcare industry. Internships are a cornerstone of professional development, giving participants a chance to deepen practical skills in a real-world setting. These programs are tailored to foster growth and prepare interns for a full-time position within the company.

    Professional Growth and Development

    UHS believes in nurturing the career growth of its team members through comprehensive professional development programs. These include leadership training, diversity training, and continuous education in the latest healthcare practices, ensuring that every team member has the opportunity to advance their career.

    Benefits and Culture

    Employment at UHS comes with competitive benefits designed to support the health, well-being, and financial security of each team member and their families. The company culture at UHS is built on a foundation of respect and inclusion, where diversity is celebrated and every voice is heard.

    Networking and Innovation

    UHS encourages a culture of innovation where team members are motivated to bring forward ideas that drive improvement and efficiency. Networking within the company is supported through various events and internal platforms, helping team members to connect, share insights, and collaborate on projects.

    Applying for a Position

    To apply for a position at UHS, candidates should prepare their resume to highlight relevant experience and skills. The interview process at UHS is thorough, aiming to assess not only the professional qualifications but also the alignment with the company’s values and culture. Interested candidates can visit the UHS Careers page to submit an application and learn more about the hiring process.

    Stay Connected with UHS Careers

    Keep up to date with the latest from UHS Jobs and Careers through the company’s dedicated careers blog. Subscribe to receive updates on new job opportunities, employment tips, and insights into the healthcare industry directly from the professionals at UHS.

    Join UHS

    Discover the rewarding career opportunities at UHS. Search for open positions that match individual skills and interests. UHS looks for passionate, curious, and solution-driven team players ready to make a significant impact in the healthcare sector.

    SEARCH UHS JOBS

    READ CAREERS BLOG

    Job Alert Emails

    Personalize your subscription to receive job alerts, latest news, and insider tips tailored to your preferences. Explore the exciting and rewarding opportunities that await at UHS.
    Learn more about UHS
    Industry
    Hospitals & Medical Centers
    * Ladders Estimates

    Similar Jobs

    Ad banner background

    Get Ready For Your
    Next Interview

    More Jobs at UHS

    More Healthcare Jobs

    Find similar DIRECTOR - UTILIZATION REVIEW jobs:

    NationwideSan Juan, PR