Director of Utilization Review

We are seeking a Director of Utilization Review (UR) to join our team. The Director of UR is responsible for overseeing the processes that ensure patient care is medically necessary, efficient, and appropriately reimbursed. This role operates at the intersection of clinical care, hospital finance, and health insurance to monitor bed days, prevent denials, and manage compliance across health systems, hospitals, or insurance companies.

Requirements

Responsibilities:

·         Designing short- and long-term Utilization Management (UM) strategies to optimize resource allocation and cost-containment

·         Ensuring the organization complies with state and federal healthcare regulations, alongside guidelines from accrediting bodies

·         Collaborating with insurance companies to resolve payment disputes, manage length-of-stay (LOS) approvals, and handle complex appeals or peer-to-peer physician reviews

·         Provides documentation training to clinical staff to ensure that patient medical records accurately reflect their treatment acuity

·         Analyzing data to identify care bottlenecks, reduce claim denials, and implement evidence-based clinical practices

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