Director Enterprise Utilization Review

PVH Potomac Valley Hospital; United States; Remote; USD 90,000 - 130,000; Full time

Job summary

A leading healthcare organization is seeking a Director of Utilization Review to oversee utilization review functions across assigned hospitals. This role requires collaboration with clinical leaders to ensure compliance and operational improvements. Candidates should possess a Bachelor's degree in Finance, Business Administration, or Nursing, along with significant experience in healthcare management.

Qualifications

• Five years of healthcare management experience in utilization, finance, or case management.
• Experience with EPIC system changes related to Utilization Review.

Responsibilities

• Direct utilization review functions for assigned hospitals, managing medical necessity and denials.
• Oversee compliance with utilization review metrics and communicate data to leadership.
• Advocate for utilization review processes with insurance carriers.

Skills

Organizational skills

Effective communication

Proficiency in computer applications

Knowledge of ICD-10 and CPT coding

Understanding of payer relations

High-level analytical skills

Education

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

Master’s Degree in Business Administration or Public Health

Job description

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Job Summary

Responsible for the direction of the utilization review functions of the health system regarding patient status and level of care. Collaborates with key stakeholders and clinical leaders to ensure compliance, efficiency, and continuous improvement. Provides system opportunities that drive operational improvements, 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 statements describe the general nature of work for this role. They are not exhaustive; other duties may be assigned as needed.

1. Act as 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 report key data and ensure process consistency.
3. Serve as administrative chair of assigned hospital Utilization Review committee, ensuring effective policy implementation and process adherence.
4. Oversee divisions interacting with clinical leaders to ensure compliance with utilization review metrics and indicators.
5. Communicate and analyze data for senior leadership and stakeholders to foster system-wide improvements and consistency.
6. Monitor key statistics to identify process improvements; communicate findings to finance, clinical, and compliance leadership.
7. Collaborate with Case Management Directors on local issues related to medical necessity and process improvements, providing guidance on utilization review functions.
8. Advocate for utilization review and escalation processes with insurance carriers, ensuring consistency and efficiency.
9. Serve as the key IT contact for EPIC system changes related to Utilization Review.
10. Coordinate with physician advisor groups, Medical Director of Utilization Management, and external advisors to develop best practices.
11. Manage the assigned cost center, including budgeting, accounts payable, and variances.

Physical Requirements

Ability to sit for prolonged periods and perform manual dexterity tasks. Reasonable accommodations may be made for individuals with disabilities.

Work Environment

Office and clinical settings. Reasonable accommodations available.

Skills and Abilities

• Organizational skills, including time management, prioritization, multitasking, and 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 coding, insurance authorization, reimbursement regulations, and medical terminology.
• Understanding of payer relations, claims processing, and revenue cycle management.
• Knowledge of clinic policies, reimbursement statistics, and healthcare metrics.
• High-level analytical skills and initiative, with the ability to understand clinical workflows and implement improvements.

Additional Job Details

• Scheduled Weekly Hours: 40
• Shift: Exempt, United States of America
• Company: West Virginia University Health System
• Cost Center: 553 SYSTEM Utilization Review

About the Company

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