Director Enterprise Utilization Review

UHC United Hospital Center; United States; Remote; USD 90,000 - 130,000; Full time

Job summary

UHC United Hospital Center is seeking a Director of Utilization Review to oversee utilization review functions and ensure compliance within the healthcare system. This role requires collaboration with clinical leaders and management of the utilization review committee, focusing on operational improvements and compliance. Candidates should possess a Bachelor's degree and significant healthcare management experience.

Qualifications

• Five years of healthcare management experience in utilization, finance, or case management.
• Bachelor’s degree required; Master's preferred.

Responsibilities

• Directs utilization review functions and collaborates with clinical leaders.
• Oversees compliance with utilization review metrics and process improvements.
• Acts as administrative advocate regarding utilization review and insurance escalations.

Skills

Organizational skills

Effective communication

Proficiency in computer applications

Knowledge of ICD-10, CPT coding

Understanding of healthcare metrics

Education

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

Master’s Degree in Business Administration or 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.

Responsible for the direction of the utilization review functions of the health system in regards to patient status and level of care. Works in collaboration with key stakeholders and clinical leaders to ensure compliance, efficiency, and improvement. Provide 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 statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be 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. System oversight of Utilization Review functions and processes, providing guidance to system directors of case management, coordinating monthly collaboration/affinity calls, and identifying site system improvements.
3. Administrative chair of the assigned hospital Utilization Review committee, ensuring effective implementation of policies and process initiatives.
4. Oversees divisions interacting with clinical leaders to ensure compliance with utilization review metrics.
5. Provides communication and analysis to senior leadership regarding initiatives and improvements, promoting consistency across the health system.
6. Oversees key statistics to facilitate process improvements and ensures communication with finance, clinical, and compliance leadership.
7. Works with Case Management Directors on local issues, providing guidance and oversight.
8. Acts as system administrative advocate regarding utilization review and insurance carrier escalations.
9. Serves as the key IT contact for EPIC changes related to Utilization Review.
10. Coordinates with physician groups and collaborates on best practices with the Medical Director of Utilization Management.
11. Manages the assigned cost center, including accounts payable, budgeting, and variances.

Physical Requirements

Ability to sit for prolonged periods, manual dexterity.

Working Environment

Office and clinical settings.

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 (word processing, spreadsheets, email).
• Knowledge of ICD-10, CPT coding, insurance authorization, revenue cycle, and reimbursement regulations.
• Understanding of healthcare metrics and clinical workflows.
• High initiative and self-starting ability.

Additional Job Details

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

About the Company

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