Director of Utilization Review

The Director of Utilization Review oversees and develops clinical services including utilization review, peer reviews, case management and quality assurance. Director of UR manages day-to-day operations of all the Utilization Review nursing staff, intake and support staff. – Supervision and development of UM nurses (remote and local), intake and support staff– Reviewer coordination and relation. – Scheduling, planning and delivery of services – Delivery of quality of UR Services – Maintains client contractual compliance and Utilization Review Accreditation Committee (URAC) compliance. – Development processes, policies Procedures within the department – Manages continuous improvement in the quality of care and service provided – Review all reviews for appropriate documentation and turn-around time – Responsible for reporting the appeal and denials and back up for the denial and appeal log – Auditing denial / appeals and log on a monthly basis – Make recommendations regarding : staffing, training, CEU opportunities and allocation of resources – Annual performance evaluations of organizational staff – Collaborates with other departments within the organization for ongoing collaboration – Assist with delegation and resolution of complaints – Assist with development and coordination of quality program – Collaborates with other departments and serves as a liaison to improve communication and customer service Job Requirements – Current RN / BSN / BA in Nursing and / or Business Healthcare Management At least 5 years experience in Utilization Management, Case Management and / or Quality Management CCM, ABQURARP or other UR designation preferred At least 5 years clinical experience PC literate, including Microsoft Office products Leadership / management / motivational skills Strong organizational skills Excellent interpersonal skills Excellent negotiation skills Ability to work in a team environment Ability to travel Ability to meet or exceed Performance Competencies