Job Description

The UTILIZATION REVIEW MANAGER requires effective communication and coordination with the Director of Utilization Review, Utilization Review Case Managers, insurance companies, and treatment team to obtain the maximum benefits for our clients. The position entails coordinating all aspects of the company’s utilization review process to ensure that every patient receives quality care through utilization of adequate resources in the most cost-effective manner. The individual in this position has overall responsibility for utilization performance improvement, denied authorizations, and operational management of the Center for Discovery Utilization Review Department. The position entails coordinating and managing concurrent and retrospective reviews of all patient’s medical records over the continuum of care. The UR manager oversees admission, concurrent and peer review as well as denials and appeals. The UR Manager ensures cases are reviewed and responded to in a timely and clinically sound manner in accordance with policies and procedures.

RESPONSIBILITIES

• Direct oversight of Center for Discovery UR Managers
• Apply utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
• Oversee Communication to third-party payers for initial and concurrent clinical review.
• Document actions and information shared with care team members or third-party payer
• Provide ongoing clinical documentation trainings to ensure charts are aligned with insurance company guidelines.
• Collect data on variances in LOC, lost days, costs/barriers to discharge/transition and denied days
• Train and oversee staff on preparing appeals on denied cases when appropriate
• Perform, train and oversee staff on completing peer reviews when required by third party payer, consulting with medical director, program director, and other staff as appropriate
• Review all aspects of care, ensuring optimal length of stay
• Review the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness.
• Develop goals and objectives; policies and procedures related to the operational needs of the programs scenarios.
• Involve appropriate facility management in all decisions and review these decisions with Director of UR prior to implementation.
• Assure adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate.
• Assure adequate orientation for new employees of the UR Case Management Department.
• Ensure an adequate system of communication and reporting is maintained between all DMAP staff members, as well as other departments involved in the ongoing operation of the program.
• Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem-solving actions.
• Demonstrate a professional attitude and supports the objectives of the facility philosophy through internal and external communications and interactions with all levels of staff, patients, community and referral sources.

For a virtual tour of the facility, please visit our website at centerfordiscovery.com.

Qualifications

Due to the nature of our business we need a compassionate understanding person with:

• Required Master’s Degree preferred but not required
• Licensed LMFT, LCSW, LVN, or RN preferred but not required
• Strong knowledge of ASAM dimensions and APA guidelines
• Knowledge of DSM-V Codes
• Knowledge of SUD, ED, and Mental Health programs

Additional Information

We are proud to be an EEO employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, or national origin.

For more information about our company benefits, please visit us at discoverybehavioralhealth.com/careers/