ESSENTIAL FUNCTIONS:

· Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.

· Conducts and oversees concurrent and retrospective reviews for all patients.

· Act as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.

· Collaborates with physicians, therapist and nursing staff to provide optimal review based on patient needs.

· Collaborates with ancillary services in order to prevent delays in services.

· Evaluates the UM program for compliance with regulations, policies and procedures.

· May review charts and make necessary recommendations to the physicians, regarding utilization review and specific managed care issues.

· Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

OTHER FUNCTIONS:

· Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

· Bachelor's degree in nursing or another clinical field required. Master's degree in clinical field preferred.

· Six or more year's clinical experience with the population of the facility preferred.

· Four or more years’ experience in utilization management required.

· Three or more years of supervisory experience required.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

· If applicable, current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.