Director Enterprise Utilization Review

WH Wheeling Hospital Inc.; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

A leading healthcare organization is seeking a Director of Utilization Review. This role involves overseeing utilization review functions, collaborating with clinical leaders, and ensuring compliance and operational improvement. The ideal candidate will have extensive healthcare management experience and strong organizational skills.

Qualifications

• Five years of healthcare management experience in utilization, finance, or case management.

Responsibilities

• Direct utilization review functions for the health system.
• Collaborate with clinical leaders to ensure compliance and efficiency.
• Advocate system-wide for utilization review and insurance carrier escalations.

Skills

Organizational skills

Time management

Multitasking

Problem-solving

Effective communication

Education

Bachelor’s Degree in Finance

Bachelor’s Degree in Business Administration

Bachelor’s Degree in Nursing

Master’s Degree in Business Administration

Master’s Degree in Public Health

Job description

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.

Responsibilities

Responsible for the direction of the utilization review functions of the health system regarding patient status and level of care. Works in collaboration with key stakeholders and clinical leaders to ensure compliance, efficiency, and improvement. Provides system opportunities that will drive operational improvement, compliance, consistency, and collaboration.

Minimum Qualifications

Education, Certification, and/or Licensure

• Bachelor’s Degree in Finance, Business Administration, or Nursing.

Experience

• Five (5) years of healthcare management experience in utilization, finance, or case management.

Preferred Qualifications

Education, Certification, and/or Licensure

• Master’s Degree in Business Administration or Public Health.

Core Duties and Responsibilities

The following are the general responsibilities for this role. Other duties may be assigned as needed.

1. Acting Director of Utilization Review for assigned hospitals, including inpatient medical necessity management and post-discharge denials management, with reporting and process improvement initiatives.
2. Provide system oversight for Utilization Review functions and processes, guiding system directors and coordinating monthly collaboration calls to ensure consistency and identify system improvements.
3. Serve as administrative chair of the hospital Utilization Review committee, ensuring effective policy implementation and process initiatives.
4. Oversee divisions interacting with clinical leaders to ensure compliance with utilization review metrics.
5. Communicate and analyze data for senior leadership and stakeholders to promote system-wide improvements.
6. Monitor key statistics to inform process improvements and coordinate communication with finance, clinical, and compliance leadership.
7. Collaborate with Case Management Directors on local issues and oversee their Utilization Review functions.
8. Advocate system-wide in relation to utilization review and insurance carrier escalations, ensuring consistency and efficiency.
9. Act as the key IT contact for EPIC changes related to Utilization Review.
10. Coordinate with physician advisor groups and develop best practices in collaboration with Medical Directors.
11. Manage assigned cost center, including budgeting, accounts payable, and variances.

Physical Requirements

Ability to sit for prolonged periods, manual dexterity, and other physical demands necessary for job performance. Reasonable accommodations may be provided.

Work Environment

Office and clinical settings, with accommodations as needed.

Skills and Abilities

• Organizational skills, time management, multitasking, problem-solving.
• Effective communication with patients, physicians, staff, and the public.
• Proficiency in computer applications such as word processing, spreadsheets, and email.
• Knowledge of ICD-10, CPT, insurance authorization, and reimbursement procedures.
• Understanding of healthcare metrics and clinical workflows.
• High initiative and self-starting abilities.

Additional details include scheduled weekly hours, shift, exemption status, company information, and cost center.