Utilization Review Manager – Manager
Position Overview: The Manager of Utilization Review management will direct the operations and staff for the department. Assists in the development of processes and policies for utilization management that optimizes patient outcomes and cost efficiency of services. Works closely with Medical, Clinical teams and primary therapists in order to monitor utilization management decisions for quality, quantity, accuracy, and adherence to established criteria. Also works with insurance companies as a patient advocate to negotiate authorization for appropriate patient care.
* Manages the Utilization Review Team and their related caseloads and schedules.
* Consistently works to develop new and innovative systems to help maximize patient days.
* Provides reliable trending analysis of current and past data related to length of stay and days authorized by specific insurance companies.
* Works with in-network and out-of-network benefits to help maximize patient days.
* Works closely with the Medical Team, Clinical Team and Primary Therapists.
* Attends Treatment Team meetings.
* Maintains knowledge and experience with all continuums of care, including admission assessment and continued stay criteria.
* Ensures quality and quantity of documentation in medical records for UR.
* Maintains knowledge of pre-assessment and pre-certification reviews and be able to perform appeal reviews.
* Maintains knowledge of discharge planning resources
* Establishes relationships with key insurance accounts to help troubleshoot difficulties.
* Stay up-to-date with changes in State and Federal laws and regulations regarding insurance/third party payers.
* Ensures compliance with State and accreditation requirements/guidelines.
* This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Education and Experience:
* Masters level Clinician plus 2 years of experience preferred or;
* LPN/RN plus 2 years of experience.
* Two years of experience in utilization review in a hospital or behavioral health care setting, including one year of supervisory experience; or equivalent combination of training, education, and experience.
* Able to work as a member of the treatment team.
* Knowledge of State and Federal Statutes regarding patient confidentiality laws.
* Knowledge of State guidelines and accreditation agency standards.
* Lead and Engage Staff: Articulate a vision that inspires others. Attract, develop and retain top talent.
* Decision making: Makes good decisions based on clear understanding and evaluation of relevant information; gathers information and involve others as appropriate.
* Personal Effectiveness/Credibility: Delivers results on promised information. Builds effective relationships and establishes a reliable track record.
* Collaboration: Works in collaboration with other health professionals and leaders from other disciplines.
* Customer Relationship Management: Engages customers interactively using technology, marketing and customer services with the goal of improving business relationships, assisting in customer retention and driving sales growth.Company Description
At Recovery Centers of America, our addiction treatment philosophy centers around offering evidence-based, individualized addiction treatment solutions for individuals & families struggling with drug & alcohol addiction – as well as co-occurring disorders. With an individualized approach to addiction treatment and a comprehensive continuum of care, we heal patients – and their families—from a life of active addiction & alcoholism to a life of hope and healing. We deliver comprehensive addiction treatment services in a safe and comfortable environment. Our addiction treatment services include drug and alcohol detoxification, individual and group therapy, family counseling services for both patient and family, case management, life skills training, 12 Step education, psychiatric care, individualized aftercare planning, and recovery resources designed to support patients for life. With evidence-based treatment practices at each one of our neighborhood-based locations, we offer each patient and their family the highest quality addiction treatment services and an opportunity to heal, regain hope, rebuild and recover – for life. If you or a loved one is struggling with addiction, don't wait, call or text us now at 1-800-RECOVERY or visit us at 1800RECOVERY.com