DIRECTOR - UTILIZATION REVIEW

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. Oversee the utilization reviews, organization determinations 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. Ensure that denial and appeal letters are responded to in accordance with industry standards. Responsibilities and essential duties : Oversee Utilization Review Processes : 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 clinical protocols, and organizational policies. Keep abreast of any legal or regulatory changes that impact on the UR functions and operations to ensure timely implementation. 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. Conduct regular audits of utilization reviews to ensure adherence to policies and procedures, documentation of cases in established tools, use of best practices, and ethical standards. Available daily for case analysis, as required. Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards. Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services. Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management. Ensure Compliance and Quality Control Provides assertive, effective, and consistent supervision to assure quality control and service excellence. 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. Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation. 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. Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets. 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. Supervises the Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director. Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care. Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement. 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. Responsible for conducting internal audits within UR Department. Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs. Comply with FHC Compliance Department requests to assure internal and clients’ compliance requirements. Training and Development Train UR staff and psychiatrists in the best practices, regulatory requirements, and documentation standards. Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines. Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees. Encourages the staff attendance and participation to the educational activities. Communication Demonstrates effective communication skills and reports to the VP of Clinical Affairs. Maintains open communication with peers and the staff. Keeps the staff informed about changes or situations related to department processes. Meet with staff on a regular basis, one on one, and conduct monthly meetings or as needed. Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes. Communicate with patients and families about treatment options and the rationale for service denials, when appropriate. 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. Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system. Works in collaboration with other departments of the organization. Represents the organization in different activities and meetings. Develop and Implement Policies In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan. Establish and update UR policies and procedures to optimize services and resource use. Ensure staff adherence to protocols regarding case reviews, authorization processes, and members’ assessments. Effectively manages staff related matters in accordance with the rules, personnel policies and procedures. Develops an annual vacation plan taking into consideration the service needs and the employees requests. Keeps the specialization license and professional association membership (colegiación) effective as it corresponds to the specialization, if apply. Meets with the mandatory trainings, such as : the Annual Compliance Plan, HR trainings, etc.