The Director of Utilization Review is accountable for managing the Utilization Review functions of the hospital system in accordance with legislative and accrediting agencies guidelines. Reports to the Director of Revenue Cycle supervises the Utilization Review Coordinators and Case Managers. This position has frequent contacts with Physicians, patients, department heads, senior management, nursing staff, social services, and state and federal agencies.

Serves as the Director of Case Management responsible for implementing operation of the Case Management and Utilization Management Programs for the system.  The Director of Case Management is accountable for overall program development, implantation and coordination, in accordance with organizational directive, protocols, and policies and procedures, as well as adhering to the organizational Mission, Vision and Values. Manages activities necessary to ensure appropriate utilization of the hospital and its resources while maintaining optimal achievable standards of patient care. Maintains the strictest confidentiality of all patient information.

• Designs and maintains an ongoing Utilization Review Program to monitor and evaluate the quality and appropriateness of patient care.
• Assures that each department has a written plan for the Utilization Review
• Program and that these plans are current.
• Serves as chairperson, staffs the Continuum of Care Committee to identify problems in the Utilization Review Program, and makes recommendations to the Director of Revenue and follows through to correct these problems.
• Reviews the Utilization Review program and makes recommendations to the Director on how to improve the quality of patient care.
• Oversees and maintains a program for patient record review and assure that these records are complete, and proper codes recorded to justify the admission length of stay, the appropriateness and the cast effectiveness of care, and the optimization of re-imbursement.
• Issues in-house denials for extended length of stays
• Serves on various hospital committees as required
• Keeps abreast of current Utilization Review standards and regulations
• Interviews, selects, evaluates personal or recommend such action as necessary.
• Formulates and prepares budgets, work reports and other administrative guides
• Performs other related duties as assigned
• Responsible for assuring and ongoing Utilization Review Program designed to objectively and systematically monitor and evaluate the appropriateness of patient care, purse opportunities to improve patient care, and resolve and identify problems
• Responsible for monitoring and evaluating patient care information collected to evaluate the activities involving admissions and continued stay reviews to detect any problems, trends, etc., in utilization of hospital facilities, maximize reimbursement and assure compliance with federal and state regulations and accrediting agencies.
• Coordinates Case Management Departments and works with staff and leaders to accomplish departmental and organization objectives.
• Guides and directs the case managers and other leaders, including the medical staff, to develop, monitor and trend outcomes related to clinical/critical pathways.
• Stays abreast of developments in the case management field and provides ongoing education to the leaders and staff within the facility.
• Oversees the case management function and serves as a liaison between the case managers and hospitals and medical staff. Manages and leads the Case Management, Social Service, and Utilization Management staff to integrate their activities to facilitate a smooth and non-duplicative process.
• Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff and others to overcome barriers to discharge.
• Maintains knowledge of applicable DNV standards and other regulatory agency requirements and works with leaders within the organization to maintain ongoing compliance.
• Ability to develop and implement PI activities and ensure delivery of customer service

Education

Registered nurse (licensed in state of employment) from an accredited School of Nursing. Bachelor Degree in nursing and Certified Case Manager preferred.

Minimum Work Experience

Minimum of two (2) years experience in a managerial position in a clinical setting preferred.

Required Skills, Knowledge, and Abilities

Demonstrated ability to analyze, synthesize, report and manage patient care information typically obtained through previous experience in utilization review or case management.

Strong Professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the Organization.

Ability to lead, support and build on current efforts of various groups working within the department’s scope of work.

Ability to extensively communicate effectively with outside agencies, third-party payors and regulators.

Function independently under the guidance of the Diretor within the broad scope of department and organization-wide policies, practices and common goals.

In depth knowledge of InterQual Criteria Sets