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

• Managing the ongoing authorization process with commercial payors, Medicaid, and Medicare to secure coverage for continued inpatient/outpatient psychiatric care

• Ensuring documentation aligns with strict behavioral health mandates, including Joint Commission standards, state mental health laws, and the Mental Health Parity and Addiction Equity Act (MHPAEA)

• Collaboratively work with Business Office to identify and appeal denied days within designated contractual protocols

• Acting as a central point of contact between clinical staff, billing departments, and third-party payers

• Attends FLASH providing updates of scheduled and unscheduled discharges

• Perform other duties as per the requirements of the organization.

Qualifications:

Bachelor's degree in a related field (e.g., nursing, social work, healthcare administration) or equivalent work experience. 5 years’ experience in a hospital setting with at least (2) in utilization review, claims review, or management review in progressive roles. Previous training or demonstrated competence in negotiations, quality assurance or case management outcomes helpful.

Knowledge, Skills, and Abilities:

• Exceptional verbal and written skills to translate complex insurance rules to therapists, psychiatrists, and families

• Skilled in drafting compelling, evidence-based clinical appeals and prepping psychiatrists for complex peer-to-peer reviews

• Advanced understanding of mental health and substance-related disorders, diagnostic criteria, and standard treatment modalities

• Thorough understanding of Medicaid, Medicare, commercial managed care plans, and prior authorization workflows

• The ability to remain objective and advocate fiercely for patient care needs while simultaneously protecting the facility from financial loss

• Ability to identify systemic bottlenecks in clinical charting that lead to repeated insurance denials and implement systemic fixes

• Monitor team performance indicators, such as time elapsed from admission to prior authorization request, percentage of concurrent review approvals, and the team's successful appeal rate

• Provide continuous education on shifting insurance policies and regional managed care updates so coordinators feel equipped

• Ability to motivate, train, and guide a diverse team of clinicians, social workers, and nurses through shifting healthcare law

• Proficiency in Microsoft Office Suite and other related software to perform necessary tasks

• Perform other duties as per the requirements of the organization

Benefits

• Health Insurance

• Vision Insurance

• Dental Insurance

• 401K Retirement Plan

• Healthcare Spending Account

• Dependent Care Spending Account

• PTO Plan

• Life Insurance (Supplemental Life, Term, and Universal plans are also available.)

• Short and Long-Term Disability (with additional buy-in opportunities)