Director Enterprise Utilization Review

WVU Medicine; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

WVU Medicine is seeking an experienced Director of Utilization Review to oversee healthcare management functions. The role involves collaboration with clinical leaders to ensure compliance and operational improvements. Candidates should possess a Bachelor's degree and significant healthcare management experience. This position offers a dynamic work environment with opportunities for leadership and process enhancement.

Qualifications

• Five years of healthcare management experience in utilization, finance, or case management.
• Knowledge of payer relations, claims adjudication, and reimbursement procedures.

Responsibilities

• Direct utilization review functions and ensure compliance.
• Manage assigned cost center and financial aspects.
• Coordinate with clinical leaders on utilization review metrics.

Skills

Organizational Skills

Problem Solving

Communication

Analytical Abilities

Education

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

Master’s Degree in Business Administration or Public Health

Tools

ICD-10 Codes

CPT Coding

Microsoft Office

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.
• Collaborate with key stakeholders and clinical leaders to ensure compliance, efficiency, and improvement.
• Provide system opportunities that drive operational improvement, compliance, consistency, and collaboration.

Minimum Qualifications

Education, Certification, and/or Licensure

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

Experience

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

Preferred Qualifications

Education, Certification, and/or Licensure

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

Core Duties and Responsibilities

The statements here describe the general nature of work and are not all-inclusive. Other duties may be assigned.

1. Act as Director of Utilization Review for assigned hospitals, managing inpatient medical necessity and post-discharge denials, including reporting and process improvements.
2. Oversee utilization review functions and processes across the system, providing guidance and coordinating monthly collaboration/affinity calls.
3. Serve as administrative chair of the hospital Utilization Review committee, ensuring effective policy implementation.
4. Ensure compliance of utilization review metrics and indicators through interaction with clinical leaders.
5. Provide communication and analysis to senior leadership regarding initiatives and improvements.
6. Manage key statistics and communicate findings to finance, clinical, and compliance leadership.
7. Work with Case Management Directors on local issues, providing oversight and guidance.
8. Advocate in relations with insurance carriers, ensuring consistency and efficiency.
9. Serve 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 the assigned cost center, including budgeting and financial management.

Physical Requirements

Ability to sit for prolonged periods, manual dexterity, and other physical demands necessary to perform essential functions.

Working Environment

Office and clinical settings, with accommodations as needed for disabilities.

Skills and Abilities

1. Organizational skills including time management, prioritization, and multitasking.
2. Effective communication and relationship-building skills.
3. Proficiency in computer applications such as MS Word, Excel, and email.
4. Knowledge of ICD-10, CPT coding, insurance authorization, and reimbursement procedures.
5. Understanding of healthcare metrics like CMI, LOS, and utilization review.
6. High initiative and self-starting capabilities.

Additional Job Information

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