Director of Utilization Review

The Director of Utilization Review provides strategic leadership and oversight of utilization management activities, including utilization management, cost containment, daily department operations, delegation oversight, and clinical program initiatives. The Director develops and manages daily operations, focusing on improving clinical and financial outcomes. He/she motivates others to balance patient needs and business process. Responsible for developing strategy to drive continual business growth built on a foundation of exceptional clinical care and quality provided to our patients.

Essential Job Duties:

• Leads and directs the utilization review function for treatment facilities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or services. Engages in peer to peer conversations to guide and support deliver of evidence-based care.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Manages treatment facility audits of operational process, patient care plan and medication documentation.
• Determines policies an