Utilization Review Manager (Full Time, Towson)

General Summary:

• Under general supervision, provides day-to-day leadership of the utilization review process of patients admitted to the Hospital for Inpatient and Day Hospital levels of care.
• Trains or ensures the proper training of newly hired Utilization Review Coordinators, coordinates work assignments, and provides effective liaison between Admissions and Finance/Revenue Cycle.
• Communicates with clinical programs and other internal departments as needed. 
• Updates the Hospital Utilization Review Plan and ensures that the plan is administered as documented. 
• Performs the full range of duties associated with Utilization Review Coordinator during coverage for absences and vacancies or as workload requires. 
• These duties include the review of patient medical records for evidence of medical necessity and appropriateness of admission/continued stay, case review for appeals of payment denials, and the review and assessment of the adequacy of clinical information sent to insurance companies. 
• Maintains and reports data as required.

Knowledge, Skills, and Abilities Required:

• Work requires comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services and intervention techniques, and knowledge of utilization review practices and procedures – acquired through a Master's degree in social work, counseling, nursing, or related field
• Must hold one of the following licenses in the state of Maryland: LCSW-C, LCPC, RN.
• Work requires 3 to 5 years of progressively more responsible utilization review experience in a psychiatric setting in order to provide leadership for the Utilization Review Program in compliance with the Joint Commission (TJC) and State of Maryland requirements, understand insurance company/payor policies and issues, and effectively represent department in liaison role.
• Work requires interpersonal skills sufficient to provide leadership to assigned staff and to communicate with tact and diplomacy with a variety of clinicians and other Hospital staff as well as third-party reimbursement payers and reviewers in gathering and exchanging information, consulting, and solving problems.
• Work requires a relatively high level of analytical skill sufficient to collect, analyze, and interpret data to determine importance of information collected, form inferences and/or forecasts on how to utilize data, and prepare abstracts and summaries of statistical information for reports.
• Work requires the ability to concentrate and pay close attention to detail when collecting and analyzing data, maintaining files, and preparing required reports, and very frequently produces a high level of mental/visual fatigue.
• Work requires walking and standing when visiting Hospital locations in order to gather data or talk with internal staff and clinicians.
• If the candidate holds a RN license: In keeping with the Maryland Board of Nursing guidelines, all nurses must have an active Maryland nursing license to practice in the state of Maryland, or must have an active license in a compact state that allows them to practice in Maryland, if they reside in that compact state. A multistate licensee who changes primary state of residence to another party state shall apply for a multistate license in the new party state within 60 days. The rule requires that a nurse apply for a new license in a new primary state of residence within 60 days of relocating, it does not require the new license be issued withing 60 days.

Benefits:

At Sheppard Pratt, you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

• A commitment to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation
• Comprehensive medical, dental and vision benefits for benefit eligible positions
• 403b retirement match
• Generous paid-time-off for benefit eligible positions
• Complimentary Employee Assistance Program (EAP)
• Generous mileage reimbursement program

Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.