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Director of Utilization Review (Sacramento)

Company: Northern California Behavioral Health System
Location: Sacramento
Posted on: January 15, 2022

Job Description:

POSITION TITLE: Director of Utilization ReviewREPORTS TO (TITLE): Chief Financial OfficerDESCRIPTION OF POSITION:The primary role of this position is to monitor adherence to the hospital's utilization review plan ensuring optimal reimbursement for hospital services. Key responsibilities include working with all departments providing patient care services to monitor appropriateness of hospital admissions and extended hospital stays. The person in this role serves as the content expert in house trainer in utilization review, appeals processes and related procedures.KEY RESPONSIBILITIES:

  • Conducts admission reviews: Works closely with Assessment and Referral (A&R) staff to stay abreast of admissions. Facilitates accurate and timely collection from Assessment & Referral staff to initiate and coordinate pre-authorization procedures. Organizes and presents patient information to third party payers for prompt pre-certification process. Obtains and documents patient data from physicians for admission reviews.
  • Conducts concurrent and extended stay reviews: Actively participates in treatment team meetings to collect, and subsequently report, patient information to submit for payment of medical services. Develops, implements, and tracks upcoming utilization reviews; this includes collaborating with treatment team members to gather and report information in a timely manner. Alerts attending physician when payers require physician reviews. Effectively negotiates flexing of medical benefits as appropriate and may participate in discharge planning and alternative placement options.
  • Manages appeals to third party payers: Collects pertinent data to support provider and patient's circumstance relative to appeals for payment of medical services. This encompasses interpreting third party payer policies and preparing formal payment appeals within limited time constraints. Works closely with Chief Executive Officer on cost effectiveness of appeals. Monitors details on denied charges and days of admission. Initiates written and verbal communication to address trends of denials and success of appeals. Submits all appeals on or before required response date.
  • Manages utilization department programs: Maintains and updates logs of review activity including denied charges and days. Records and files department records; prepare reports as requested by Chief Executive Officer. Participates in weekly denial management meetings. Prepares reports of trends and patterns of utilization or resources or denials with corrective action plan. Collaborates with Chief Executive Officer, Chief Nursing Officer, Chief Financial Officer and Director of Social Services in evaluation of utilization review program, productivity, and annual reviews.
  • Monitors payer policies: Maintains high level of expertise regarding third party payer policies and requirements. This includes retaining coverage details on a wide variety of third-party payer plans while also acting as a resource for clinical staff in payment and reimbursement practices. Provides training and coaching to ensure a clinical criterion is documented as required by hospital and regulatory commissions.
  • Department Leadership: Carries out personnel management activities associated with direct staff supervision. This includes recruitment screening and selection, orientation training and staff development, performance management, and employee relations functions. Assists in the development of organization goals. Approves expenditures, reviews timesheets, and signs checks as appropriate.
  • Other: Upholds the Organization's ethics and customer service standards. Performs related duties as requested.RequirementsEducation, Licensing and Certification:
    • Registered Nurse, Licensed Vocational Nurse, Licensed Clinical Social Worker, or Licensed Marriage Family Therapy required.
    • Current Cardiopulmonary Resuscitation (CPR) certification, or within 30 days of hire
    • Crisis Prevention Institute (CPI) obtained within 30 days of hireKnowledge and Experience:
      • Knowledge of utilization review, managed care and third-party reimbursement required. Ability to apply and interpret admission, diagnostic terms, treatment modalities and continued stay criteria also required.
      • Experience with staff supervision, developing internal UR systems and workflow processes preferred.Skills and Abilities:
        • Maintains confidentiality of patients at all times.
        • Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.
        • Proficiency with computer equipment and/or software (e.g., Outlook, Word, Excel and PowerPoint).
        • Strong organizational skills with ability to prioritize projects, work independently and meet deadlines.
        • Strong written and verbal communication skills.
        • Ability to work independently and as part of a team.
        • Good judgment, problem-solving and decision-making skills.
        • Demonstrated commitment to working collaboratively. Ability to lead, influence, and motivate others.
        • Ability to work in a fast-paced, expanding organization.Physical Requirements:While performing the duties of this job, this position is frequently required to do the following:
          • Use standard office equipment and access, input, and retrieve information from a computer.
          • Give and follow verbal and written instructions with attention to detail and accuracy.
          • Perform complex mental and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, analyze complex data and information. Coordinate multiple tasks simultaneously.
          • Vision: see details of objects at close range.
          • Reach forward, up, down, and to the side. Sit or stand for minimum periods of one hour at a time and come and go from the work area repeatedly throughout the day. Lift up to twenty-five (25) pounds.BenefitsEligible employees receive holiday premium pay, health, dental & vision insurance, 401(k), healthcare & dependent care spending accounts, generous paid time off, life insurance, company-paid short and long-term disability coverage. Whether you are in intern looking to earn licensing hours, a health care worker looking for PRN work or a professional looking for a career, the opportunities are abundant at Sacramento Behavioral Healthcare Hospital.

Keywords: Northern California Behavioral Health System, Sacramento , Director of Utilization Review (Sacramento), Executive , Sacramento, California

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