Director of Utilization Review
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What you'll do
- Lead the daily work of the utilization review team and monitor the use of hospital services.
- Direct concurrent, continued stay, and retrospective medical record reviews.
- Work to prevent avoidable claim denials and handle clinical appeals and peer-to-peer reviews.
- Partner with physicians, therapists, nursing staff, and the revenue cycle team to prevent delays in care and support proper reimbursement.
- Keep the department aligned with state, federal, accreditation, and insurance payer rules.
- Monitor the appropriateness of hospital admissions and extended hospital stays.
- Prepare and submit appeals to third party payors.
- Manage hiring, training, mentoring, and performance management for UR staff.
What they're looking for
- Active clinical license (RN, LCSW, LMFT, LPC) required.
- Minimum five (5) years of experience in healthcare utilization management/review, preferably in a behavioral health setting.
- Minimum three (3) years of supervisory or management experience required.
- Strong understanding of medical necessity criteria and local insurance payer guidelines.
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
Desert Parkway Behavioral Healthcare Hospital is dedicated to delivering compassionate, high-quality care for patients with psychiatric and mental health needs. We focus on patient-centered recovery across multiple levels of care. We are seeking a strategic leader to join our team.
The Director of Utilization Review manages the day-to-day operations of our Utilization Review (UR) department. You will lead a team that tracks authorized care, monitors lengths of stay, and ensures that clinical documentation supports medical necessity. You act as the main bridge between our clinical staff, medical providers, and external insurance payers.
Key Responsibilities
- Lead the daily work of the utilization review team and monitor the use of hospital services.
- Direct concurrent, continued stay, and retrospective medical record reviews.
- Work to prevent avoidable claim denials and handle clinical appeals and peer-to-peer reviews.
- Partner with physicians, therapists, nursing staff, and the revenue cycle team to prevent delays in care and support proper reimbursement.
- Keep the department aligned with state, federal, accreditation, and insurance payer rules.
- Monitor the appropriateness of hospital admissions and extended hospital stays.
- Prepare and submit appeals to third party payors.
- Manage hiring, training, mentoring, and performance management for UR staff.
Requirements
- Active clinical license (RN, LCSW, LMFT, LPC) required.
- Minimum five (5) years of experience in healthcare utilization management/review, preferably in a behavioral health setting.
- Minimum three (3) years of supervisory or management experience required.
- Strong understanding of medical necessity criteria and local insurance payer guidelines.
Benefits
A full benefits package is available the first of the month following 30 days of employment!
Desert Parkway offers competitive benefits to include:
- Medical insurance
- Dental insurance
- Vision insurance
- 401K Retirement Plan
- Healthcare spending account
- Dependent care spending account
- PTO Plan with holiday premium pay
- Discounted cafeteria meal plan
- Life insurance (including plans for spouse and children)
- Short- and long-term disability (with additional buy-in opportunities)
- Pet Insurance
- Identity Theft Insurance
Company
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