Assistant Director, Utilization Review (On-site)

Nexus Enterprises LLC•Schertz, TX

11d•Onsite

About The Position

The Assistant Director, Utilization Review partners with the Director, Utilization Review to lead, supervise, and train the Utilization Review Department. The role combines team leadership with analysis and reporting of complex production data to support operational excellence, efficient allocation of administrative nursing resources, and continuous improvement in review processes. The position also performs utilization and quality reviews, including pre-authorization, concurrent, and retrospective medical-necessity reviews involving Workers’ Compensation, Group Health, Disability, and other systems. Reviews include evaluating clinical information in laboratory and radiology reports and multidisciplinary progress notes. The role is based onsite in Schertz, Texas, and reports to the Director, Utilization Review.

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 and convey information effectively to management, staff, and other stakeholders.
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 determine and apply appropriate evidence-based guidelines.
Extensive knowledge and understanding of Utilization Review.
Ability to identify and define potential or current issues independently, gather and analyze relevant data, establish facts, draw valid conclusions, and apply sound judgment and discretion.
Proficient computer skills, including navigating multiple software systems and using Microsoft Word, Excel, and Outlook.

Nice To Haves

Experience in a previous management role.

Responsibilities

Partner with the Director to provide leadership, supervision, training, and direction for the Utilization Review Department, supporting appropriate workload distribution and team performance.
Gather and analyze data with the Director to prepare individual performance evaluations for Utilization Review Nurses.
Establish and monitor workflow processes and production goals with the Director, including collecting, aggregating, analyzing, and reporting production metrics.
Maintain knowledge of regulatory changes and communicate updates to Utilization Review Nurses in a timely manner.
Work with the Director to develop nurse-retention strategies and incentive programs.
Partner with the Director to design and implement educational initiatives.
Assist the Director with case audits for nurses in training, providing guidance to promote quality standards and development.
Help distribute training cases to provide equitable exposure to different request categories, clients, and state guidelines and requirements.
Support call coverage and answer 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; evaluate clinical information in laboratory reports, radiology reports, and multidisciplinary progress notes.
Conduct a low to moderate amount of case-specific research.
Produce high-quality professional reports with accurate grammar and spelling.
Dictate all report information.
Communicate and coordinate effectively with team members and vendors in spoken and written formats.