Director Enterprise Utilization Review

WTZ Wetzel County Hospital; United States; Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare organization seeks a Director of Utilization Review to oversee compliance and operational improvements. This role involves collaboration with clinical leaders, managing utilization review processes, and ensuring effective policy implementation. The ideal candidate will have strong organizational and communication skills, along with a background in healthcare management. This position offers a dynamic work environment with opportunities for professional growth.

Qualifications

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

Responsibilities

• Directing utilization review functions and collaborating with stakeholders.
• Managing financial aspects of the assigned cost center.
• Overseeing compliance with utilization review metrics.

Skills

Organizational Skills

Time Management

Problem-Solving

Effective Communication

Relationship-Building

Analytical Skills

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

Tools

ICD-10

CPT Coding

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 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 general responsibilities and may include other duties as assigned:

1. Acting Director of Utilization Review for assigned hospitals, including inpatient concurrent medical necessity management and post-discharge denials management, reporting, and process improvement initiatives.
2. Provide system oversight related to Utilization Review functions and processes, guiding system directors of case management, coordinating monthly collaboration calls, and identifying site system improvements.
3. Serve as the 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 and indicators.
5. Communicate and analyze data for senior leadership and stakeholders, promoting consistency across the health system.
6. Manage key statistics to facilitate process improvements and ensure communication with Finance, Clinical, and Compliance leadership.
7. Work with Case Management Directors on local issues, providing guidance and oversight of their utilization review functions.
8. Act as the system administrative advocate for utilization review and escalation with insurance carriers, ensuring work functions are consistent and efficient.
9. Serve as the key IT contact for EPIC changes or implementation related to Utilization Review.
10. Coordinate with physician advisor groups and Medical Directors to develop best practices and external collaborations.
11. Manage the assigned cost center, including financial aspects such as accounts payable, budgeting, and variances.

Physical Requirements

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

Work Environment

Office and clinical settings. Reasonable accommodations may be made.

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 programs, ICD-10, CPT coding, insurance authorization, and reimbursement procedures.
• Knowledge of healthcare metrics, clinical workflows, and process improvement techniques.
• Self-starter with high initiative and analytical skills.

Additional Job Details:

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