DIRECTOR - UTILIZATION REVIEW

Universal Health Services • Guaynabo, PR

196d

About The Position

The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. This position provides strategic leadership to the daily operations of the Utilization Review Department, ensuring compliance with CMS regulatory standards and other relevant accrediting bodies. The UR Director oversees the utilization reviews, organization determinations, and appeals processes in accordance with established policies and procedures, maintaining full compliance with industry standards.

Requirements

• Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
• Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling.
• Valid membership for Social Work and Psychiatric Nursing.
• A minimum of five years' experience in the mental health field, with three or more years in a leadership role in utilization review or mental health case management.
• Knowledge in Microsoft Office.
• Fully Bilingual.

Responsibilities

• Oversee Utilization Review Processes
• Lead the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies.
• Manage and supervise the UR team, setting standards for reviewing mental health services.
• Keep abreast of any legal or regulatory changes impacting UR functions.
• Supervise the review process to ensure requests for mental health treatment are approved or denied based on established clinical criteria.
• Conduct regular audits of utilization reviews to ensure adherence to policies and procedures.
• Be available daily for case analysis as required.
• Ensure denial and appeal letters are documented and mailed in the established timeframe.
• Identify potential risks related to mental health service delivery and utilization.
• Develop strategies to mitigate risks and improve response timelines for preauthorization requests.
• Ensure Compliance and Quality Control
• Provide assertive supervision to assure quality control and service excellence.
• Ensure compliance in the preparation and implementation of corrective action plans.
• Maintain effective communication with supervised personnel regarding findings and plans.
• Assure daily census count of members admitted to different facilities.
• Contribute to compliance with organizational and individual goals based on financial targets.
• Comply with recommendations from monitoring agencies.
• Supervise Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director.
• Analyze utilization data to identify trends and opportunities for cost-saving.
• Prepare and present reports on utilization trends and key performance indicators.
• Conduct internal audits within the UR Department.
• Work with all departments for the development and monitoring of quality improvement programs.
• Training and Development
• Train UR staff and psychiatrists in best practices and regulatory requirements.
• Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
• Identify areas of development for staff and coordinate necessary training.
• Encourage staff attendance and participation in educational activities.
• Communication
• Demonstrate effective communication skills and report to the VP of Clinical Affairs.
• Maintain open communication with peers and staff.
• Keep staff informed about changes related to department processes.
• Meet with staff regularly and conduct monthly meetings.
• Serve as the primary liaison with insurance companies and regulatory bodies.
• Communicate with patients and families about treatment options and service denials.
• Maintain effective communication with the case management program and Access Center.
• Demonstrate initiative in integration efforts across all levels of care.
• Develop and Implement Policies
• Work with the VP of Clinical Affairs on developing and revising departmental policies.
• Establish and update UR policies and procedures to optimize services.
• Ensure staff adherence to protocols regarding case reviews and authorization processes.
• Manage staff-related matters in accordance with personnel policies.
• Develop an annual vacation plan considering service needs and employee requests.
• Keep specialization license and professional association membership effective.

What This Job Offers

• Industry: Hospitals
• Education Level: Master's degree
• Number of Employees: 5,001-10,000 employees