Manager – Utilization Review

Overview

PURPOSE STATEMENT:

Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs. 

Responsibilities

ESSENTIAL FUNCTIONS:

• Provide consultation and guidance regarding admissions and patient length of stay to a variety of payers.
• Secure authorizations with insurance companies for inpatient treatment and continue to obtain authorizations for duration of patient stay.
• Evaluate the utilization program for compliance with regulations, policies and procedures.
• Review clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment.
• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

Qualifications

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• If applicable, current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility requirements.

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