Assistant Director, Utilization Review (On-site)
About The Position
The Assistant Director, Utilization Review partners with the Director of Utilization Review to lead, supervise, train, and direct the Utilization Review Department. The role supports workload distribution, team performance, nurse training, and operational processes. It also collects, aggregates, analyzes, and reports production data to support resource allocation and continuous improvement in review processes. The position performs utilization and quality reviews, including pre-authorization, concurrent, and retrospective medical-necessity reviews involving Workers’ Compensation, Group Health, Disability, and other systems. Reviews involve evaluating clinical documentation such as laboratory and radiology reports and multidisciplinary progress notes. The role also contributes to case audits and training, communicates regulatory updates, and produces professional reports.
Requirements
- BSN and 1–2 years of experience in a Managed Care setting.
- Current and unrestricted RN license.
- Experience with various state evidence-based medicine guidelines.
- Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence.
- Ability to produce clear, accurate reports, formal correspondence, and training materials for diverse audiences.
- Strong grammar, spelling, punctuation, document-formatting, oral communication, and written communication skills.
- Comprehension of medical/surgical modalities and imaging techniques.
- Ability to analyze clinical documentation in relation to medico-legal review.
- Ability to interpret and apply appropriate guidelines to medico-legal reviews.
- Ability to use logic and reasoning to select and apply appropriate evidence-based guidelines.
- Extensive knowledge and understanding of Utilization Review.
- Ability to identify and define issues independently, gather and analyze relevant data, establish facts, draw valid conclusions, and exercise sound judgment and discretion.
- Proficient computer skills, including ability to navigate multiple software systems and knowledge of Microsoft Word, Excel, and Outlook.
Nice To Haves
- Experience in a previous management role.
Responsibilities
- Partner with the Director of Utilization Review to provide department leadership, supervision, training, and direction and support workload distribution and team performance.
- Gather and analyze data for individual performance evaluations of Utilization Review Nurses.
- Establish and monitor workflow processes and production goals, including collection, aggregation, analysis, and reporting of production metrics.
- Maintain knowledge of regulatory changes and communicate updates to Utilization Review Nurses.
- Develop strategies for nurse retention and incentive programs with the Director.
- Design and implement educational initiatives with the Director.
- Assist with case audits for nurses in training and provide guidance to promote quality standards and development.
- Distribute training cases to provide equitable exposure to request categories, clients, and state guidelines and requirements.
- Support call coverage and respond to questions from nurses during their initial four-week training period.
- Conduct intermittent utilization and quality reviews.
- Perform pre-authorization, concurrent, and retrospective medical-necessity reviews involving Workers’ Compensation, Group Health, Disability, and other systems.
- Research cases as needed.
- Produce high-quality professional reports and dictate report information.
- Communicate and coordinate with team members and vendors in spoken and written formats.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
