DIRECTOR OF UTILIZATION REVIEW
Apply NowCompany: UHS
Location: Guaynabo, PR 00971
Description:
Responsibilities
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversees the utilization review, organization's determination and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensures that denial and appeal letters are responded to in accordance with industry standards.
Responsibilities and task :
1. Oversee Utilization Review Processes:
a. Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with insurance guidelines, clinical protocols, and organizational policies.
b. Keep abreast of any legal or regulatory changes that impact the UR functions and operations to assure timely implementation.
c. Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines.
d. Conduct regular audits of utilization reviews to ensure adherence to policies and processes, documentation of cases in established tools, use of best practices, and ethical standards.
e. Available daily for case analysis, as required.
f. Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards.
g. Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services.
h. Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management.
2. Ensure Compliance and Quality Control
a. Provides assertive, effective, and consistent supervision to assure quality control and service excellence.
b. Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments.
c. Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation.
d. Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards.
e. Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets.
f. Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC.
g. Supervises the Interrater Reliability Tests with the Medical Director.
h. Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care.
i. Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement.
j. Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others.
k. Responsible for conducting internal audits within the UR Department.
l. Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs.
m. Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements.
3. Training and Development
a. Train UR staff and psychiatrists on best practices, regulatory requirements, and documentation standards.
b. Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
c. Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees.
d. Encourages the staff attendance and participation to the educational activities.
4. Communication
a. Maintains an open communication with peers and the staff.
b. Keeps the staff informed about changes or situations related to department processes.
c. Meet with staff on a regular basis, one on one and conducts monthly meetings or as needed.
d. Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes.
e. Communicate with patients and families about treatment options and the rationale for service denials, when appropriate.
f. Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions.
g. Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system.
h. Works in collaboration with other departments of the organization.
i. Represents the organization in different activities and meetings.
5. Develop and Implement Policies
a. In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan.
b. Establish and update UR policies and procedures to optimize services and resource use.
c. Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments.
d. Effectively manages staff related matters in accordance with the rules, personnel policies and procedures.
e. Develops an annual vacation plan taking into consideration the service needs and the employees requests.
f. Keeps the specialization license and professional association membership ( colegiacin ) effective as it corresponds to the specialization, if apply.
g. Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.
h. Exemplifies of Service Excellence standards.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
Notice
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or [redacted] .
Qualifications
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversees the utilization review, organization's determination and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensures that denial and appeal letters are responded to in accordance with industry standards.
Responsibilities and task :
1. Oversee Utilization Review Processes:
a. Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with insurance guidelines, clinical protocols, and organizational policies.
b. Keep abreast of any legal or regulatory changes that impact the UR functions and operations to assure timely implementation.
c. Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines.
d. Conduct regular audits of utilization reviews to ensure adherence to policies and processes, documentation of cases in established tools, use of best practices, and ethical standards.
e. Available daily for case analysis, as required.
f. Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards.
g. Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services.
h. Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management.
2. Ensure Compliance and Quality Control
a. Provides assertive, effective, and consistent supervision to assure quality control and service excellence.
b. Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments.
c. Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation.
d. Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards.
e. Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets.
f. Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC.
g. Supervises the Interrater Reliability Tests with the Medical Director.
h. Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care.
i. Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement.
j. Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others.
k. Responsible for conducting internal audits within the UR Department.
l. Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs.
m. Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements.
3. Training and Development
a. Train UR staff and psychiatrists on best practices, regulatory requirements, and documentation standards.
b. Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
c. Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees.
d. Encourages the staff attendance and participation to the educational activities.
4. Communication
a. Maintains an open communication with peers and the staff.
b. Keeps the staff informed about changes or situations related to department processes.
c. Meet with staff on a regular basis, one on one and conducts monthly meetings or as needed.
d. Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes.
e. Communicate with patients and families about treatment options and the rationale for service denials, when appropriate.
f. Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions.
g. Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system.
h. Works in collaboration with other departments of the organization.
i. Represents the organization in different activities and meetings.
5. Develop and Implement Policies
a. In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan.
b. Establish and update UR policies and procedures to optimize services and resource use.
c. Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments.
d. Effectively manages staff related matters in accordance with the rules, personnel policies and procedures.
e. Develops an annual vacation plan taking into consideration the service needs and the employees requests.
f. Keeps the specialization license and professional association membership ( colegiacin ) effective as it corresponds to the specialization, if apply.
g. Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.
h. Exemplifies of Service Excellence standards.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
Notice
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or [redacted] .
Qualifications
- Education: Master's in Social Work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
- Licenses: Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling in the relevant jurisdiction, and Professional Associating Membership (colegiacion).
- Relevant Work Experience: A minimum of five years' experience in the mental health field, working directly with patients or in clinical services supervision. Must have three or more years of experience in a leadership role specifically in the utilization review area or in mental health case management field.
- Fully Bilingual (English and Spanish)
- Knowledge in: Microsoft Office