The Director Utilization Management is responsible for oversight and management of all utilization review/case management activities for the facility's inpatient, partial hospitalization, and outpatient programs. This position oversees all aspects and daily processes of the Utilization Management department. Conducts audits of all medical records to ensure criteria for admission and continued stay are met and documented and ensures timely discharge planning. Coordinates information between third party payers and medical/clinical staff members. Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards.

Essential Functions:

Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner. Oversight of daily reviews of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to (1) determine appropriateness and clinical necessity of admissions, continued stay, and or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.e. H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and (3) identify any under-, over-, and/or inefficient use of services or resources. Reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems. Coordinates flow of communication between physicians/staff and third-party payers concerning reimbursement requisites; oversight of daily concurrent reviews and the follow through with documentation requests from third party payers; maintains abstract with updates provided to third party payers. Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share with those attending any pertinent data from third-party payer contracts; also attends weekly treatment team meeting. Oversight of the notification to physicians/staff/patients of reimbursement issues; initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received; reports monthly all Hospital Issued Notices of Non-coverage (HINN letter) to QIO. Upon notification by business office that potential exists to be included on a new managed care contract, makes contact with the managed care company and coordinates communications between Oceans Payer Engagement department, administration and the managed care company to obtain contractual arrangements. Maintains coordination of information requests from third party payers and Oceans Payer Engagement team for all annual renewal or update of existing contracts. Communicates to staff status of new/existing contracts. Working knowledge of case management duties as required and coordinates flow of communication among staff involved in the patient's care; completes paperwork for judicial commitments and state bed packets. Working knowledge of the referral process and necessary paperwork for all other levels of care and make follow-up appointments; including follow-up letters needed by the patient. Working knowledge and experience to conduct special retrospective studies/audits when need is determined by M&PS and /or other committee structure. Performs other duties and projects as assigned.