Director of Utilization Review
Department: Quality Management
Shift: 1st Shift
The Director of Utilization Review (UR) must have well-developed skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual leads the Case Management and Clinical Documentation Improvement departments. The Director of UR is responsible for developing and/or maintaining effective processes for determining the appropriate admission status based on the requirements of various commercial and government payers.
This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews. The Director of UR will ensure that appropriate data is tracked, evaluated, and reported. This individual monitors the effectiveness of the UM program by evaluating overall data trends and key metrics. The Director of UR will prepare UM reports as required for a variety of GHS audiences. This person will design and implement process improvements as needed.
This individual leads and/or actively participates with a variety of departments and multi-disciplinary teams. The Director of UR maintains current and accurate knowledge of commercial and government payers, as well as The Joint Commission regulations/CoP’s related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures. The Director of UR ensures that all UM processes have valid outcome measures.
The Director of UR effectively manages a diverse workload in a fast-paced, rapidly-changing, regulatory environment. This role collaborates with multiple leaders at various levels throughout GHS (including directors and vice presidents) for the purpose of supporting and improving the UM program.
RN Licensed in State of Illinois Preferred Bachelor’s in Nursing and 2 years of relevance clinical nurse experience. Current Illinois license is required