Director Enterprise Utilization Review

HARR Harrison Community Hospital; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

A leading healthcare provider is seeking a Director of Utilization Review to oversee utilization review functions, ensure compliance, and drive operational improvements. The role requires strong leadership and collaboration with clinical leaders to enhance patient care and operational efficiency.

Qualifications

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

Responsibilities

• Act as Director of Utilization Review for assigned hospitals.
• Oversee utilization review functions and processes across the system.
• Serve as administrative chair of the hospital Utilization Review committee.

Skills

Organizational Skills

Problem Solving

Effective Communication

Relationship Building

Knowledge of ICD-10

Knowledge of CPT Coding

Knowledge of Insurance Authorization

Knowledge of Revenue Cycle

Knowledge of Reimbursement Regulations

Understanding of Healthcare Metrics

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

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Responsibilities

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 improvement. Provides system opportunities that 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 general responsibilities of the role. 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. Oversee utilization review functions and processes across the system, providing guidance and coordinating monthly collaboration calls to ensure process consistency and identify improvements.
3. Serve as administrative chair of the hospital Utilization Review committee, ensuring effective policy implementation and process initiatives.
4. Monitor compliance of utilization review metrics and indicators in collaboration with clinical leaders.
5. Provide communication and analysis to senior leadership regarding initiatives and improvements, promoting system-wide consistency.
6. Manage key statistics to drive process improvements and communicate findings to finance, clinical, and compliance leadership.
7. Work with Case Management Directors on local issues related to medical necessity and process improvements, providing oversight of their functions.
8. Advocate for utilization review and escalation with insurance carriers to ensure consistency and efficiency.
9. Serve as the key IT contact for EPIC system changes related to utilization review.
10. Coordinate with physician advisor groups and collaborate with the Medical Director of Utilization Management to develop best practices.
11. Manage the assigned cost center, including financial aspects such as 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 made for individuals with disabilities.

Work Environment

Work primarily in office and clinical settings, with accommodations available as needed.

Skills and Abilities

• Strong organizational, time management, prioritization, and problem-solving skills.
• Effective communication and relationship-building abilities 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, revenue cycle, and reimbursement regulations.
• Understanding of healthcare metrics and clinical workflows for process improvement.
• High initiative and self-starting attitude.

Additional Information

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