Regional Director of Utilization Review

Overview

The Regional Director of Utilization Review with leadership duties is accountable for oversight of the Utilization

Review functions across ARH. Reports to the System Director of Case Management/Utilization Review and

supervises the Regional Utilization Review Coordinators and Regional Utilization Review Supervisor/Manager.

This position has frequent contacts with Physicians, patients, department heads, senior management, nursing

staff, social services, and state and federal agencies. Responsible for overseeing day-to-day operations of the

Utilization Management Program across the organization and resolving issues as/when they arise. The Director

is accountable for overall program development, implantation and coordination, in accordance with

organizational directive, protocols, department policies and procedures management, as well as adhering to

the organizational Mission, Vision and Values. Manages activities necessary to ensure appropriate utilization of

the hospital and its resources while maintaining optimal achievable standards of patient care. Maintains the

strictest confidentiality of all patient information.

Responsibilities

Designs and maintains an ongoing Utilization Review Program to monitor and evaluate the

quality and appropriateness of patient care.

· Assures that each department has a written plan for the Utilization Review Program and that

these plans are current.

· Serves as chairperson, staffs the Continuum of Care Committee to identify problems in the Utilization Review Program, and makes recommendations to the Administrator to assure that department heads follow through to correct these problems.

· Reviews the Utilization Review program and makes recommendations to the System Director of CM/UR on how to improve the quality of patient care.

· Oversees and maintains a program for patient record review and assures that these records are complete, and proper codes recorded to justify the admission length of stay, the appropriateness and the cast effectiveness of care, and the optimization of re-imbursement.

· Issues in-house denials for extended length of stays

· Serves on various hospital committees as required

· Keeps abreast of current Utilization Review standards and regulations

· Interviews, selects, evaluates personal or recommend such action as necessary; collaborates with Regional Utilization Review Supervisor/Manager to ensure staffing levels are appropriate based on assigned services/staffing assignment and “flex” as needed based on daily census.

· Formulates and prepares budgets, work reports and other administrative guides

· Responsible for assuring and ongoing Utilization Review Program designed to objectively and systematically monitor and evaluate the appropriateness of patient care, purse opportunities to improve patient care, and resolve and identify problems

· Responsible for monitoring and evaluating patient care information collected to evaluate the activities involving admissions and continued stay reviews to detect any problems, trends, etc., in utilization of hospital facilities, maximize reimbursement and assure compliance with federal and state regulations and accrediting agencies.

· Responsible for the total management and supervision of the Utilization Review Department.

· Coordinates with the Case Management Department and works with staff and leaders to accomplish departmental and organization objectives.

· Guides and directs the case managers and other leaders, including the medical staff, to develop, monitor and trend outcomes related to clinical/critical pathways.

· Stays abreast of developments in the case management field and provides ongoing education to the leaders and staff within the facility.

· Manages and leads the Utilization Management staff to integrate their activities to facilitate a smooth and non-duplicative process, serves as liaison between case management, social services, and their respective hospital leaders as needed.

· Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff and others to overcome barriers to discharge.

· Maintains knowledge of applicable DNV standards and other regulatory agency requirements and works with leaders within the organization to maintain ongoing compliance.

· Ability to develop and implement PI activities and ensure delivery of customer service

Qualifications

Education

Registered nurse (licensed in state of employment) from an accredited School of Nursing with CCM Certification. Masters level preferred. Willing to obtain licensure in additional states, as needed, within 6 months of hiring.

Minimum Work Experience

Minimum of two (2) years’ experience in a managerial position in a clinical setting preferred.

Required Skills,Knowledge, and Abilities

Demonstrated ability to analyze, synthesize, report and manage patient care information typically obtained through previous experience in utilization review or case management. Strong Professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the Organization including physicians, committees, senior management, trustees, patients and their families. Ability to lead, support and build on current efforts of various groups working within the department’s scope of work. An ability to extensively communicate effectively with outside agencies, third-party payors and regulators. Function independently within the broad scope of department and organization-wide policies, practices and common goals. In depth knowledge of InterQual Criteria Sets. Strong critical thinking and problem-solving skills.