Westborough, Massachusetts
Director of Utilization Management/Review. Job Opening in Westborough, Massachusetts - Westborough Behavioral Healthcare Hospital will be opening in the Summer 2017!
Director of Utilization Management/Review .
We have an exciting opportunity reporting to the Chief Financial Officer, this position manages the daily operations of the Utilization Management staff for Westborough Behavioral Healthcare Hospital. The position will work closely with the Medical Director and the Director of Clinical Services to assure a sound Utilization Management Program.
Job Responsibilities:
Monitoring the hospital's utilization review plan and appropriateness of hospital admissions and extended hospital stays, ensuring the effective and efficient use of hospital services in order to optimize reimbursement for the hospital.
Responsible for the coordination and management of U.M. activities provided during the patient?s treatment in the hospital continuum.
Directs, guides, and supervises the activities of U.M. staff to maintain the highest quality of services provided and appeals and resolves managed care organization/ insurance company denials.
Supports the organization's strategic business development efforts; maintain an active involvement and awareness of all patient admissions, discharges and transfers; maintains a liaison with the Clinical Services Department and assists in facilitating timely discharge planning;
Prepares utilization management reports for monthly medical staff meetings; conducts periodic quality audits; participates in quarterly meetings with 3rd party payors; trains staff on UR processes and procedures.
Implements Utilization Programs and policies and procedures to ensure that all functions meet internal, Health Plan, and Regulatory requirements. Ensures that patients receive appropriate authorization and access to care, including timely information regarding authorizations.
Collaborates closely with the Medical Director and the Director of Clinical services to identify opportunities for process improvement in utilization management that are consistent with the organization?s vision and strategic long-term goals.
Responsible for recruitment, hiring, training, development, and retention of UM staff. Responsible for orientation of new staff, on-going training, mentoring, and performance reviews. Conducts staff meetings, assuring policy and procedures are adhered to and when necessary, modified to address changing strategic objectives.
Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting.
Other responsibilities as assigned.
Knowledge, Skills and abilities required:
Demonstrated knowledge of health care service delivery systems and third party reimbursement.
Knowledge of managed care environment.
Ability to apply and interpret admission and continued stay level of care criteria.
Understanding of admission and discharge functions.
Familiarity with medical terminology, diagnostic terms and treatment modalities.
Knowledge of medical record keeping.
Familiarity with applicable standards and regulations.
Able to comprehend psychiatric evaluations, consults, lab results, etc.
Strong interpersonal, organizational, evaluative, and time management skills
Policy interpretation skills
Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system.
Dynamic leader with attention to detail, flexibility, responsiveness to deadlines; assertive, persistent, and persuasive.
Excellent verbal and written communication skills.
Ability to lead and form a collaborative team.
Knowledge of NCQA and other regulatory agency requirements pertaining to delivery of health care in a managed care setting.
Effective influencing, negotiation, and communication skills are essential.
Ability to work effectively under pressure due to changing priorities.
Effective employee management skills.
Possess strong leadership, critical-thinking and motivational skills/abilities.
Knowledge of healthcare delivery and management systems.
Excellent problem-solving and organizational skills.
Ability to work effectively and establish and promote positive relationships with both internal and external parties.
Education & experience:
Master?s degree in nursing, social work, psychology, or other related healthcare field is preferred
RN, LICSW, LMHC, or related license preferred
Experience with managed care reviews preferred
Experience in psychiatric setting preferred
Requires five (5) years? utilization management experience. Three (3) years management experience in a progressive leadership role required.
For more information about our programs, please visit us at:
Job Type: Full-time
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