Manager - Utilization Review

PURPOSE STATEMENT: Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.

Provide consultation and guidance regarding admissions and patient length of stay to a variety of payers. Secure authorizations with insurance companies for inpatient treatment and continue to obtain authorizations for duration of patient stay. Evaluate the utilization program for compliance with regulations, policies and procedures.

Review clinical documentation from denied stays against criteria to determine if documentation is adequate for requested treatment. Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation. OTHER FUNCTIONS: Perform other functions and tasks as assigned.

LICENSES/DESIGNATIONS/CERTIFICATIONS: If applicable, current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services. CPR and de-escalation and restraint certification required (training available upon hire and offered by facility). First aid may be required based on state or facility requirements.

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