Director- Utilization Review

Overview
The Utilization Review Nurse plays a critical role in ensuring that patients receive appropriate care while optimizing healthcare resources. This position involves evaluating medical documentation, assessing the necessity of services provided, and ensuring compliance with established guidelines. The ideal candidate will possess a strong background in nursing, along with expertise in utilization management and health information systems.

Description

Provides accurate and complete clinical information to payors based on synthesized documentation in the medical record.

Conducts utilization review on all assigned cases and ensures authorizations are completed timely with all dates of service reviewed.

Completes retrospective reviews on assigned cases when updated insurance information becomes available subsequent to admission or after discharge.

Communicates discharges timely to payors for all assigned cases.

Collaborates and consults with Director of Utilization Review and Business Office Director on retrospective reviews, denials and appeals to maximize efforts to obtain authorization and overturn of adverse determinations.

Communicates denials to Director of Utilization Review and Business Office Director by ensuring accurate entry on the Denial Tracking Log.

Provides necessary data for Denial Committee Meeting and completes minutes.

Maintains the unfunded and underutilized days logs and reports to the UR Director monthly.

Completes HMS entry in real time to include authorization numbers in Patient Maintenance.

Completes HMS entry in real time in the Utilization Review module with details of authorization/denial determinations dates of service authorized/denied, payor contact, and next steps

Notifies attending physician, Director of Clinical Services and unit staff of in-house denial decisions.

Attends unit rounds daily and treatment team meetings for assigned patients.

Serves as a co-facilitator for rounds by being prepared to discuss authorization status, anticipated third party review challenges and/or requirements for authorization.

Collaborates with the treatment team regarding quality and completeness of documentation and serves as a resource for nursing and clinical staff on documentation requirements.

Communicates with the responsible staff when clinical documentation is unclear, incomplete, unprofessional, not relevant to the Master Treatment Plan goals and/or fails to supports medical necessity criteria for continued stay at the current level of care.

Participates in routine weekly chart auditing as assigned to ensure ongoing compliance with regulatory requirements.

Coordinates and schedules peer reviews on assigned cases and follows through with medical staff and payors to ensure peer reviews and expedited appeals are completed timely, and documented in HMS with outcomes communicated to Director of Utilization Review, Business Office Director, CFO and CEO.

Discusses utilization review decisions with patients and/or family members as appropriate.

Coordinates with clinical staff regarding progress of discharge planning for patients whose care has been denied.

Effectively manages time by scheduling concurrent telephonic reviews in advance when possible to efficiently manage caseload and work hours.

Ensures coverage for any planned time away from the facility.

Communicates any incomplete work or failure to manage responsibilities timely to supervisor so responsibilities can be reassigned to prevent penalties or negative outcomes.

Provides outstanding customer service.

Maintains an overall good work attitude, promoting cooperation and professionalism in interactions with other staff members.

Reports to meetings and appointments on time.

Performs other duties and responsibilities as assigned in a timely manner.

Follows facilities safety guidelines and maintains safety for oneself, clients, visitors and co-workers and on an ongoing basis is processing whether or not the environment poses any safety hazards or unsafe conditions.

Complies with responsibilities for emergency preparedness, fire plan and attends safety education/training classes.

Qualifications

Skills

Preferred

Communication

Attention to Detail

Written Communication

Oral Communication

Education

Required

Bachelors or better in Nursing/Healthcare or related field.
Bachelors or better in Social Services or related field.

Experience

Preferred

Experience in psychiatric setting

Prior UR experience

Job Type: Full-time

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift

Ability to Commute:

• Valdosta, GA 31602 (Required)

Ability to Relocate:

• Valdosta, GA 31602: Relocate before starting work (Required)

Work Location: In person