Utilization Review Manager

Christian Health Care Center•Wyckoff, NJ

17h•$95,000 - $110,000

About The Position

Christian Health is hiring a full-time Utilization Review Manager to oversee and direct all operations of the Utilization Review department. The manager ensures healthcare resources are effectively used and monitored to support positive clinical, financial, and operational outcomes. The role reviews medical record documentation promptly for regulatory and payer compliance, verifies that inpatient and partial hospitalization admissions meet medical necessity criteria for the appropriate level of care, and monitors physician-ordered support services for appropriate utilization. The manager collaborates with social services and participates in discharge planning as needed, provides timely and accurate clinical reviews to managed care organizations, and evaluates managed care denials to determine the risks and benefits of appeals. The role also requires understanding and embracing Christian Health’s mission. The manager directs the department’s clinical and operational activities, including workflow, staffing, scheduling, and timely completion of reviews. Responsibilities include maintaining denied-case statistics, supporting patients with financial information, coordinating information across programs, verifying insurance pre-certifications, and developing and reporting on department QAPI initiatives. The manager participates in policy and procedure updates, provides operational feedback and reports to the VP of Revenue Cycle, plans projects to improve efficiency and productivity, attends patient-activity meetings, oversees staff orientation and onboarding, serves on committees as directed, and maintains survey readiness. The position includes admission, continued-stay, and concurrent reviews, obtaining insurance and state authorizations, and verifying insurance and billing benefit information. The schedule is 8:00 a.m. to 4:00 p.m., Monday through Friday. Christian Health describes its workplace as supportive, mission-driven, and collaborative, with campuses, communities, service offerings, and a hospital. The salary range is $95,000 to $110,000 per year.

Requirements

Graduate of an accredited school of nursing or school of medicine.
Three to five years of clinical hospital experience; behavioral health experience is helpful.
Interpersonal skills to obtain and interpret information appropriate to patient or client needs and age for assessment of level-of-care criteria and medical necessity guidelines.
Knowledge of, or ability to learn, practices, procedures, laws, regulations, and guidelines pertaining to Behavioral Health, Medicare, Medicaid, insurance, managed care organizations, and financial reimbursement.
Leadership and supervisory ability.
Computer literacy with Microsoft Windows, Outlook, Word, Excel, and Internet/Intranet navigation.
Demonstrate compliance with the CH ASPIRE Standards of Performance.

Nice To Haves

Behavioral health experience.
Utilization review, utilization management, or quality experience.

Responsibilities

Oversee and direct all operations of the Utilization Review department.
Direct and coordinate department activities, clinical workflow, staffing, and scheduling to ensure timely and thorough completion of work.
Ensure healthcare resources are appropriately used and monitored to support clinical, financial, and operational outcomes.
Review medical records and verify that documentation meets regulatory, payer, and medical necessity requirements for inpatient and partial hospitalization levels of care.
Monitor physician-ordered support services for appropriate utilization.
Collaborate with social services and participate in discharge planning as needed.
Provide timely and accurate clinical reviews to managed care organizations.
Evaluate managed care denials and determine the risks and benefits of pursuing appeals.
Maintain an accurate, updated statistical database regarding denied cases.
Provide financial information to patients, including information about managed care, Medicare/Medicaid, and charity care, and provide guidance or refer patients to the finance department as necessary.
Ensure accurate information exchange and coordination of operations among programs.
Verify insurance pre-certifications received from sending hospitals.
Develop, monitor, review, and report on department-specific QAPI initiatives.
Participate in review and updates of department policies and procedures and other Christian Health policies and procedures as needed.
Provide regular verbal and written feedback and reports to the VP of Revenue Cycle as needed.
Plan, implement, and evaluate projects to improve operational efficiency and productivity.
Attend scheduled meetings to review patient activities.
Oversee orientation and onboarding of new department staff.
Serve on Christian Health-wide and department-specific committees as directed.
Maintain readiness for accrediting and regulatory agency surveys.
Demonstrate competency in interacting with patients age 18 and older, including geriatric patients with Dementia.
Perform admission, continued-stay, and extended-stay reviews as required.
Perform concurrent reviews and obtain insurance/MCO pre-certifications and continued state authorizations as required.
Perform insurance verification and secure billing and benefit information.
Perform other related duties as directed.