Utilization Review Assistant Director (On-site)
About The Position
The Assistant Director, Utilization Review is responsible for assisting the Director, Utilization Review with the leadership, supervision and training of the Utilization Review and Quality Departments, as well as for the collection, aggregation, analysis and reporting of complex production and quality assurance data. The data will be used to support the efficient utilization of administrative nursing resources and review improvement activities. In addition, the Assistant Director will hold an active RN License and will collaborate closely with leadership and staff to support departmental goals, strategies, programs, and projects for continuous improvement.
Requirements
- Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulation, and correspondence
- Ability to write routine reports and correspondence; and ability to present information in small groups, and large group situations to management and staff
- Ability to apply proper grammar, spelling, punctuation, and format to typed material. Must have excellent oral and written communications 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 utilize appropriate evidence-based guidelines
- Extensive knowledge of Utilization review
- Demonstrates ability to independently identify and define potential and/or current issues of concern, collect and analyze data, establish facts, draw valid conclusions, and exercise discretion and sound judgment
- BSN with 1 – 2 years’ experience in a managed care setting
- Extensive WC Management, Clinical UR and Clinical Review required
- Experience with various state evidence-based medicine guidelines
- Experience in a previous management role required
- Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook
- Possess a current and unrestricted RN license
Responsibilities
- Effectively lead, supervise and direct the workload in the Utilization Review and Quality Departments
- Collect data necessary to complete performance reviews for each Utilization Review Nurse and Quality Nurse
- Sets workflow and production expectations of the Utilization Review and Quality Departments
- Keeps current with regulation changes and communicates changes to the Utilization Review Nurses and Quality Nurses
- Works with the Director, Utilization Review in strategizing UR and QA Nurse retention and incentive programs
- Development of educational programs
- Audit cases completed by nurses in training and provide direct feedback to assist with quality development
- Oversees case distribution during the training period to provide balanced exposure to types of requests, clients, and state guidelines
- Provides coverage of call information and clarifications of nurses in training during the first 4 weeks of training
- Performs utilization and quality review on an intermittent basis
- Conducts pre-authorization, concurrent and retrospective reviews dealing with Medical Necessity from Worker’s Comp system, Group Health, Disability, etc. The review requires evaluation of clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes
- Perform a low to moderate amount of research on a case-by-case basis
- Create a high-quality, professional report free of grammar or spelling errors
- Dictates all report information
- Effectively work with all employees and vendors (both orally and in writing)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
