Utilization Review Director, Outpatient Services

Utilization Review Manager – Outpatient

LEORA is currently seeking a qualified Utilization Review Manager for a full time position at our new location in Columbus Ohio.

The primary responsibility of the utilization review manager is to collaborate with various insurance providers, including Medicaid, commercial and managed payers to complete concurrent reviews for approval of the outpatient program. Additional responsibilities include notifying payers of discharges and collaborating with discharge planners to determine appropriate length of stay and discharge plan. The utilization review manager will also coordinate peer reviews, monitor quality data related to denied days and look at potential process improvements, etc.

Other duties include reviewing medical records and preparing clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array illnesses, intensity of service, and care coordination needs are key, as the manager must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review manager works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings.

The utilization review manager manages all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the manager result in the overturning of denied claims and recovered revenue for the health care provider. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation.

Utilization Review Manager Tasks and Responsibilities:

• Analyze information gathered by investigation, and report findings and recommendations.
• Participate in treatment team and treatment planning in order to keep team aware of covered days and assist with projecting discharge date.
• Audit and analyze patient records to ensure quality patient care and appropriateness of services.
• Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.

Our employees enjoy competitive salaries and an excellent benefits package in a great team environment! If you meet the qualifications listed below, respond to this ad immediately with your resume for confidential consideration.

POSITION REQUIREMENTS

• Prior experience as a utilization review manager
• Behavioral health experience preferred
• Excellent written and oral communication skills are a must
• Must be capable of working in a fast paced environment and meeting deadlines
• Strong computer and customer service skills require.