Utilization Management Director
The Utilization Management Director is responsible for administering and managing the facility’s utilization management program.
Responsibilities
- Develops and implements the organization’s utilization management plan in accordance with the mission and strategic goals of the organization, federal and state law and regulations, and accreditation standards
- Develops and implements systems, policies and procedures for prospective, concurrent and retrospective case review, clinical practice guidelines, care maps, clinical protocols, and reporting quality of care issues identified during the utilization review process
- Educates and trains the leadership, staff, and business associates as to the utilization management plan and their respective responsibilities relative to the plan
- Collects, analyzes, and maintains data on the utilization of medical services and resources
- Prepares and presents quarterly utilization management summaries to the Board, identifying potential areas for improvement
- Reports quality of care issues identified during the utilization review process according to policy and procedure
- Acts as the liaison to the Peer Review Organization (PRO), performing duties such as the preparation of replies to PRO denials
- Obtains pre-approval or pre-certification from third-party payers for procedures and continued stay
- Actively participates or facilitates selected committees such as Utilization Management and Performance Improvement
Qualifications
- A bachelor’s degree in a clinical or allied health field
- RHIA or RHIT credential or licensure as a RN preferred
- A minimum of three years experience in utilization management, health information management, nursing, quality improvement, or a related field
- Knowledge of statistics, data collection, analysis, and data presentation
- Excellent interpersonal communication and problem-solving skills
- Knowledge of utilization management techniques
- Knowledge of ICD and CPT coding
