Health Organization

A growing behavioral health organization is conducting a confidential search for an experienced Director of Utilization Review. This leadership position offers the opportunity to oversee utilization management operations, improve reimbursement outcomes, ensure regulatory compliance, and collaborate with an interdisciplinary team dedicated to delivering exceptional patient care.

Position Summary

The Director of Utilization Review is responsible for leading all aspects of the Utilization Review program, including medical necessity reviews, payer authorizations, denial management, regulatory compliance, and staff supervision. This position works closely with physicians, nursing leadership, case management, and clinical teams to promote quality outcomes and efficient resource utilization.

Responsibilities

·         Lead the daily operations of the Utilization Review department.

·         Ensure timely submission of initial and concurrent insurance authorizations.

·         Oversee medical necessity reviews using payer-specific guidelines and industry-recognized criteria.

·         Manage peer-to-peer reviews, appeals, and denial prevention strategies.

·         Monitor key performance indicators, including authorization turnaround times, denial rates, and length of stay.

·         Ensure compliance with CMS, Joint Commission, HIPAA, and applicable state regulations.

·         Develop and implement Utilization Review policies, procedures, and best practices.

·         Supervise, mentor, and evaluate Utilization Review staff.

·         Collaborate with interdisciplinary teams to support quality patient care and financial performance.

·         Participate in Quality Assessment and Performance Improvement (QAPI) initiatives.

Qualifications

·         Minimum of LPN credentials required. A degree from an accredited college or university with emphasis in a related behavioral healthcare field or in nursing preferred.

·         Minimum of three (3) years of Utilization Review, Case Management, or Utilization Management experience in an acute care or behavioral health setting.

·         Previous leadership or supervisory experience preferred.

·         Knowledge of Medicare, Medicaid, Managed Care, and Commercial insurance authorization processes.

·         Strong understanding of behavioral health documentation standards and reimbursement guidelines.

·         Excellent communication, leadership, organizational, and analytical skills.

Compensation & Benefits

·         Competitive salary based on experience

·         Comprehensive medical, dental, vision, and life insurance

·         Paid Time Off (PTO)

·         Retirement savings plan

·         Professional development opportunities

How to Apply

Qualified candidates are encouraged to submit a current résumé and cover letter for confidential consideration. Only candidates selected for an interview will be contacted.

Equal Employment Opportunity

Seaside Health System is committed to the principle of Equal Employment Opportunity for all employees and applicants. It is our policy to ensure that both current and prospective employees are afforded equal employment opportunity without consideration of race, religious creed, color, national origin, nationality, ancestry, age, sex, marital status, sexual orientation, or disability in accordance with local, state and federal laws.

Americans with Disabilities Act

Applicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.