Director of Utilization Review & Care Optimization

SAN-Antonio-Behavioral-Healthcare-Hospital-; San Antonio (TX); On-site; USD 120,000 - 180,000; Full time

Benefits offered by this job

Health Insurance

Vision Insurance

Dental Insurance

401K Retirement Plan

Healthcare Spending Account

Dependent Care Spending Account

PTO Plan

Life Insurance

Short and Long-Term Disability

Job summary

SAN-Antonio-Behavioral-Healthcare-Hospital- seeks a Director of Utilization Review to oversee medical necessity, efficiency, and appropriate reimbursement across care settings. You will lead UM strategy, ensure regulatory compliance, and collaborate with payors to manage appeals and denials.

Ideal candidates have a Bachelor's in a related field and at least 5 years in a hospital UR or related management role, with strong leadership and communication skills.

Qualifications

• Requires a Bachelor's degree in a related field and 5 years in a hospital setting with at least 2 years in utilization review or case management.
• Experience with negotiations, quality assurance or case management outcomes is helpful.

Responsibilities

• Design UM strategies to optimize resource allocation and cost-containment.
• Ensure compliance with state and federal healthcare regulations and accrediting bodies.
• Collaborate with insurance companies to resolve payment disputes and manage LOS approvals.
• Provide documentation training to clinical staff for accurate records reflecting acuity.
• Analyze data to identify care bottlenecks and reduce denials; apply evidence-based practices.
• Manage authorization processes with commercial payors, Medicaid, and Medicare for coverage.

Skills

Verbal and written communication

Negotiation

Clinical terminology

Healthcare compliance

Data analysis

Staff leadership

Process improvement

Education

Bachelor's degree in nursing, social work, healthcare administration or related field

Tools

Microsoft Office Suite

Job description

SAN-Antonio-Behavioral-Healthcare-Hospital- seeks a Director of Utilization Review to oversee medical necessity, efficiency, and appropriate reimbursement across care settings. You will lead UM strategy, ensure regulatory compliance, and collaborate with payors to manage appeals and denials.

Ideal candidates have a Bachelor's in a related field and at least 5 years in a hospital UR or related management role, with strong leadership and communication skills.