Utilization Review Manager

NeuroPsychiatric Hospitals•Mishawaka, IN

1d•Hybrid

About The Position

Doctors NeuroPsychiatric Hospital and Medical Behavioral Hospital of Mishawaka are seeking a Utilization Review Manager to oversee utilization review services and ensure compliance with CMS Conditions of Participation. This role leads efforts to promote effective utilization of healthcare resources, coordinate patient care across the continuum, support appropriate reimbursement, and reduce denials. The Utilization Review Manager will supervise staff supporting Doctors NeuroPsychiatric Hospital and Medical Behavioral Hospital of Mishawaka, with travel between both hospitals required to provide leadership, support, and case management.

Requirements

Bachelor's degree in Nursing, Social Work, Behavioral Health, or Counseling field required.
Minimum of 5 years of utilization review experience in a hospital setting is required.
Minimum of 3 years’ experience as a supervisor and/or manager in utilization review role is required.
Proficiency with Microsoft Office, email, electronic health records, and computer systems.

Nice To Haves

Master's degree preferred.
5 years of case management experience, including discharge planning in a hospital setting preferred.
RN, LPN, Social work or Counselor State Licensure is preferred.
Case Management certification preferred.
Strong organizational, prioritization, problem-solving, and time-management skills.
Ability to work independently and collaboratively with interdisciplinary teams.
Knowledge of Utilization Management, Case Management, care management plans, and critical pathways.
Knowledge of CMS, regulatory, accreditation, and confidentiality requirements related to healthcare and utilization management.
Strong clinical data analysis, research, and documentation skills.
Excellent verbal and written communication skills with physicians, healthcare providers, patients, families, and other stakeholders.

Responsibilities

Lead and coordinate the hospital’s Utilization Review and Case Management program across designated facilities.
Promote quality, cost-effective patient care through appropriate utilization of hospital resources, including review of medical necessity, level of care, length of stay, consultations, and discharge planning.
Oversee clinical reviews of patient records and documentation to ensure medical necessity, severity of illness, and continued stay are supported by InterQual, Milliman, hospital, CMS, and other applicable regulatory standards.
Coordinate initial and concurrent reviews with payors, including precertifications, continued stay certifications, length-of-stay updates, reconsiderations, appeals, peer-to-peer reviews, external reviews, and state fair hearings as needed.
Monitor patient cases throughout the entire episode of illness and identify barriers to care, discharge planning concerns, documentation gaps, and opportunities to improve outcomes and resource utilization.
Collaborate with physicians, nurses, social workers, medical records, finance, and other interdisciplinary team members to achieve appropriate patient outcomes within established length-of-stay guidelines.
Identify trends, problematic DRGs, diagnoses, procedures, and utilization patterns and develop strategies to improve quality, resource utilization, reimbursement, and denial management.
Partner with Medical Records, Finance, and physicians to promote accurate clinical documentation and coding and ensure appropriate reimbursement.
Oversee admission and discharge audits and ensure the completeness, accuracy, validity, and reliability of patient discharge information.
Ensure required provider certifications and documentation are completed and maintained in accordance with CMS and regulatory requirements.
Maintain accurate, timely, and real-time documentation in the electronic medical record and other applicable systems.
Supervise, support, and educate Utilization Review and Case Management staff, including communicating updates to policies, procedures, regulatory requirements, and payor guidelines.
Conduct interdisciplinary team meetings and facilitate communication among healthcare providers regarding utilization, case management, discharge planning, and patient care concerns.
Develop, implement, and evaluate quality improvement and utilization management initiatives designed to improve patient outcomes and efficiently manage healthcare resources.
Develop and monitor financial goals related to designated case types and utilize data and reporting to evaluate utilization, denials, reimbursement, and quality outcomes.
Prepare and compile utilization review, denial management, case management, and other required patient and hospital reports.
Maintain current knowledge of CMS Conditions of Participation, federal and state regulations, accreditation standards, payor requirements, and emerging trends and research related to utilization management and case management.
Serve as a resource and subject matter expert for utilization review, case management, resource utilization, and case mix reimbursement.
Participate in internal and external committees, meetings, councils, workgroups, and performance improvement activities as appropriate.
Maintain current knowledge of occurrence screening and risk management practices and support compliance with applicable policies and procedures.
Adhere to NPH’s Corporate Compliance Policy, Code of Conduct, Conflict of Interest Policy, and all applicable hospital policies and procedures.
Perform other duties as assigned.