DIRECTOR OF UTILIZATION REVIEW

Department:

Utilization Review /

Case Management Reports To:

Chief Executive Officer or Designee Classification:

Full-Time, Exempt Facility:

Axiom Behavioral Health

POSITION SUMMARY

The Director of Utilization Review is a leadership-level case management position responsible for overseeing the hospital's Utilization Review and Case Management functions. This position provides operational oversight of the utilization review team while maintaining direct involvement in patient care progression, payer authorization, length-of-stay management, treatment team collaboration, and denial prevention and management.

The Director serves as a key liaison among physicians, nursing, treatment teams, case management, admissions, payers, and hospital leadership to ensure that patients receive medically necessary care at the appropriate level of care while barriers to authorization, continued stay, and timely discharge are identified and addressed.

The Director is expected to be highly visible in hospital operations and actively participate in treatment team and utilization management activities rather than functioning solely in an administrative capacity.

ESSENTIAL DUTIES AND RESPONSIBILITIES UTILIZATION REVIEW LEADERSHIP

Direct and oversee the daily operations of the Utilization Review and Case Management department. Supervise, support, and provide direction to Utilization Review staff and other assigned case management personnel. Lead daily Utilization Review meetings and communicate significant issues, trends, barriers, and payer concerns to hospital leadership. Establish accountability for timely completion of all utilization management activities. Monitor departmental workflow, assignments, productivity, and follow-up. Ensure accurate and timely documentation of utilization review activities within the hospital's designated systems.

PATIENT LENGTH-OF-STAY MANAGEMENT

Maintain active oversight of patient length of stay across the hospital. Review the patient census daily to identify patients approaching or exceeding expected lengths of stay. Identify clinical, payer, placement, discharge, or operational barriers contributing to extended hospitalization. Work collaboratively with physicians, nursing, therapists, discharge planning, and hospital leadership to address avoidable delays. Track length-of-stay trends by physician, payer, unit, diagnosis, and other relevant indicators. Escalate significant or recurring length-of-stay concerns to leadership.

TREATMENT TEAM PARTICIPATION

Attend and actively participate in interdisciplinary treatment team meetings. Provide the treatment team with relevant information regarding payer authorization, continued-stay requirements, clinical documentation needs, and anticipated review dates. Collaborate with physicians and clinical staff to ensure documentation accurately reflects the patient's current condition, medical necessity, treatment needs, progress, and barriers to discharge. Identify documentation gaps that could jeopardize continued authorization or reimbursement and work with the appropriate clinical leader to resolve them.

AUTHORIZATIONS AND CONTINUED-STAY REVIEWS

Oversee and participate in initial authorizations, pre-authorizations, concurrent reviews, continued-stay reviews, and other payer-required reviews. Ensure reviews are completed within payer-required timeframes. Maintain awareness of upcoming authorization expiration dates and ensure necessary clinical information is submitted before authorization lapses. Communicate directly with insurance companies, managed care organizations, utilization management organizations, and other payers as necessary. Coordinate peer-to-peer reviews between attending physicians and payer medical directors when required.

DENIAL MANAGEMENT

Maintain oversight of clinical and utilization-related denials. Review denials to determine the underlying cause and identify opportunities for prevention. Coordinate reconsiderations, appeals, peer-to-peer reviews, and submission of additional clinical documentation when appropriate. Track denial trends and report findings to hospital leadership. Work collaboratively with physicians, nursing, admissions, revenue cycle, and other departments to reduce preventable denials. Identify recurring documentation or process deficiencies contributing to denials and develop corrective strategies.

STATE, REGULATORY, AND EXTERNAL REVIEWS

Coordinate and oversee applicable state reviews and other external utilization or case reviews. Ensure requested clinical documentation and supporting information are complete, accurate, and submitted within required timeframes. Serve as a knowledgeable departmental resource during payer, regulatory, and utilization-related reviews. Maintain departmental processes consistent with hospital policy and applicable federal, state, accreditation, and payer requirements.

CASE MANAGEMENT AND CARE COORDINATION

Function as a senior case management resource for complex patients. Assist with difficult payer, placement, authorization, and discharge barriers. Facilitate communication across disciplines when patient progression is delayed. Promote early identification of discharge needs beginning at admission. Support appropriate transitions to the next level of care while maintaining patient safety and continuity of care.

PERFORMANCE

MANAGEMENTThe Director will monitor and report key performance indicators, including: Average length of stay Authorization and continued-stay status Pending and expired authorizations Denial rates and denial reasons Peer-to-peer outcomes Appeal outcomes Extended-stay patients Avoidable days Payer-specific trends Timeliness of utilization reviews Documentation deficiencies affecting authorization or reimbursement

QUALIFICATIONS

Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), or other appropriately qualified healthcare professional preferred. Behavioral health and/or psychiatric hospital experience strongly preferred. Previous experience in Utilization Review, Utilization Management, Case Management, managed care, or behavioral health reimbursement required. Leadership or supervisory experience preferred. Strong understanding of medical necessity, behavioral health levels of care, payer authorization processes, concurrent review, denial management, and discharge planning. Experience communicating with commercial insurance, Medicare, Medicaid, managed care organizations, and behavioral health payers preferred. Strong organizational, analytical, communication, and leadership skills. Ability to work effectively with physicians and multidisciplinary clinical teams.

POSITION

EXPECTATIONSThe Director of Utilization Review is expected to take ownership of the entire utilization management process from admission through discharge. The successful candidate will understand that utilization review is not simply an insurance function; it is an integral component of case management, patient progression, clinical documentation, reimbursement, and responsible hospital operations.

The Director must be proactive, organized, collaborative, and comfortable identifying problems and bringing solutions forward to leadership. The position requires daily engagement with patients' cases, physicians, treatment teams, payers, and the Utilization Review staff.

The ultimate objective is to ensure that every patient receives the appropriate level of care for the appropriate duration, that medically necessary treatment is supported by strong clinical documentation, and that preventable authorization delays and denials are minimized.

Pay:

From $60,000.00 per year

Benefits:

Dental insurance Health insurance Vision insurance

Work Location:

In person