Description
This position is responsible for overseeing and optimizing the utilization of resources, promoting efficiency and improving patient outcomes. The Manager of Utilization Review plays a crucial role in monitoring the quality of care provided, coordinating with various departments and implementing strategies to minimize costs while maintaining high standards of patient care.
Essential Job Functions
Oversee the Utilization Review process to ensure the appropriate and cost-effective use of healthcare resources.
Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
Lead and mentor a team of Utilization Review Specialists, providing guidance and support in reviewing patient medical records and gathering relevant clinical information.
Analyze utilization data and trends to identify opportunities for improving efficiency and reducing unnecessary costs.
Monitor and assess the performance of healthcare providers, identifying areas for improvement and implementing corrective action plans.
Stay abreast of changing regulations, guidelines, and technologies in the field of healthcare utilization management, and develop strategies to ensure compliance and enhance operational efficiency.
Maintain accurate and comprehensive documentation of all utilization review activities, ensuring compliance with organizational policies and regulatory requirements.
Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
Participate in the development and implementation of quality improvement initiatives, working collaboratively with the Quality Management team to enhance patient care outcomes.
Requirements
Minimum Qualifications
Education
4 Year / Bachelors Degree Bachelors Degree in Nursing
Experience
5 years of Experience in a clinical setting
Experience with healthcare information systems and software
Previous management or supervisory experience
Certifications and Licenses
Current Montana Registered Nurse License
