Manager - Utilization Review and Denials

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.

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