Medical Utilization Review Director

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Medical Utilization Review Director directs the team responsible for evaluating proposed and/or delivered healthcare services to determine if the services meet established health plan coverage guidelines. Receives, reviews, and acts on pre-authorization requests from service providers for medical procedures, treatments, admissions, and medications. Being a Medical Utilization Review Director reviews patient and clinical information to ensure compliance with established utilization review guidelines. Refers more complex requests and those that need clinical review to a medical reviewer. Additionally, Medical Utilization Review Director requires a bachelor's degree. Typically reports to senior management. The Medical Utilization Review Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. To be a Medical Utilization Review Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function.