Manager of Utilization Review

Position Summary

The Manager of Utilization Review (UR) manages the daily operations of the UR practices for an assigned division. Leads This position ensures timely initial, concurrent, and retrospective reviews are conducted efficiently with a high degree of accuracy. The Manager of Utilization Review collaborates with leaders throughout the company to support denial prevention strategies, regulatory compliance and process optimization. This position serves as an internal subject matter expert and frontline people leader guiding and educating team members on UR functions, tracking and maintaining performance metrics, managing workflows and cross functional collaboration in support of organizational goals.

Relationships and Contacts

Within the organization: Maintains frequent and close working relationships with the Director of Utilization Review, Utilization Review Coordinators, Revenue Cycle team members, Admissions team members, Nursing leadership, milieu leadership, and all clinical team members.

Outside the organization: Initiates and maintains strong professional relationships with clients and families, insurance carrier contacts, referral partners and vendors, as needed.

Position Responsibilities

Essential Responsibilities

1. Communicates professionally and effectively with multidisciplinary team members, insurance organizations and business offices, providing needed information in a logical, concise manner using technical language that accurately describes clients’ condition(s) and treatment needs.
2. Manages hiring and selection, onboarding training, regular coaching and supervision of Utilization Review Coordinators.
   1. Provides fair and consistent leadership and communication with team members.
   2. Promotes effective team dynamics within and between departments, facilitates team building and professional development for Utilization Review Coordinators.
3. Assists team members with challenging cases, removing barriers and increasing access to care.
4. Performs medical records reviews and ongoing training with clinical/medical team members within the assigned division.
5. Performs regular audits of Utilization Review Coordinator’s work to ensure quality and performance.
6. Maintains current knowledge of Utilization Review process and trends, including denials and concurrent reviews.
7. Revises processes in collaboration with the Director of Utilization Review to meet organizational goals, as needed.
8. Utilizes effective documentation standards that support a strong historical record of actions taken on each account.
9. Maintains a strict level of confidentiality for all client, company, departmental, and healthcare provider information.
10. Escalates challenges and/or roadblocks to Director of Utilization Review for resolution, as needed.

Additional Responsibilities

1. Maintains current knowledge of Utilization Review process, including denials and concurrent reviews.
2. Functions within the guidelines of the corporate Code of Ethics and in accordance with Corporate Compliance standards.
3. Reads, understands, adheres to, and models all company policy statements on ethics, conduct, and conflict of interests.
4. Attends and completes all training within assigned time frames.
5. Performs other duties as assigned.