Utilization Review Manager

Christian Health Care Center•Wyckoff, NJ

About The Position

The Utilization Review Manager oversees and directs the operations of the Utilization Review department, ensuring effective use and monitoring of healthcare resources to support positive clinical, financial, and operational outcomes. The manager reviews medical record documentation promptly for compliance with regulatory and payer requirements and verifies that documentation for patients admitted to inpatient and partial hospitalization programs meets medical necessity criteria for the appropriate level of care. The role monitors physician-ordered support services, collaborates with social services, participates in discharge planning as needed, and provides timely, accurate clinical reviews for managed care organizations. The manager evaluates managed care denials and determines the risks and benefits of pursuing appeals. The position directs the department’s clinical activities, workflow, staffing, and scheduling; maintains accurate denied-case statistics; and provides patients with financial information and guidance or referrals as appropriate. It coordinates information across programs, verifies insurance pre-certifications, develops and reports on department QAPI initiatives, contributes to policy and procedure updates, and provides regular feedback and reports to the VP of Revenue Cycle. The manager plans and evaluates projects to improve operational efficiency and productivity, attends scheduled patient-activity meetings, oversees new staff orientation and onboarding, serves on committees as directed, and maintains survey readiness. The role also performs admission, continued-stay, and concurrent reviews; obtains required insurance and managed-care authorizations; and verifies insurance, billing, and benefit information. The manager is expected to embrace Christian Health’s mission and demonstrate competency in interacting with adults age 18 and older, including geriatric patients with dementia. This is a full-time position scheduled 8 a.m.–4 p.m., Monday through Friday. The salary range is $95,000–$110,000 per year, with the base salary determined in part by relevant experience, education, and credentials.

Requirements

Graduate of an accredited school of nursing or school of medicine.
3–5 years of clinical hospital experience.
Interpersonal skills to obtain and interpret information appropriate to patient/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 is helpful.
Utilization review, utilization management, or quality experience is preferred.

Responsibilities

Oversee and direct all operations and clinical activities of the Utilization Review department.
Schedule and direct department workflow to ensure timely and thorough completion of work, and maintain appropriate staffing and schedules.
Review medical records for regulatory and payer compliance and verify medical necessity and appropriate levels of care for inpatient and partial hospitalization patients.
Monitor physician-ordered support services and perform admission, continued-stay, extended-stay, and concurrent reviews as required.
Obtain insurance and managed-care pre-certifications and continued-stay authorizations, including required contacts with outside agencies.
Verify insurance and secure billing and benefit information.
Provide patients with financial information regarding managed care, Medicare/Medicaid, charity care, and related matters; provide guidance or refer patients to the finance department as appropriate.
Maintain accurate and updated statistical data regarding denied cases.
Provide timely and accurate clinical reviews for managed care organizations; evaluate denials and determine the risks and benefits of pursuing appeals.
Collaborate with social services and participate in discharge planning as needed.
Coordinate the accurate exchange of information and operations among programs.
Develop, monitor, review, and report on department-specific QAPI initiatives.
Participate in review and updates of Utilization Review and other applicable Christian Health policies and procedures.
Provide the VP of Revenue Cycle with regular verbal and written feedback and reports 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 other related duties as deemed necessary and appropriate, as directed.
Comply with the CH ASPIRE Standards of Performance and embrace Christian Health’s mission.