Director of Utilization Review (Sacramento)
Company: Northern California Behavioral Health System
Posted on: January 15, 2022
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
- 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
- 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
- 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
- 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
Keywords: Northern California Behavioral Health System, Sacramento , Director of Utilization Review (Sacramento), Executive , Sacramento, California
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