Provo Canyon Behavioral Hospital is an 80 bed facility, serving the Adolescent, Adult, Detox/Rehab, and Senior population. We are actively seeking a Utilization Review Manager to share in the excitement of our growing facility. Provo Canyon Behavioral Hospital is located in Orem, Utah and is a member of Universal Health Services, Inc. (UHS). UHS is one of the nation's largest and most respected healthcare management companies, operating through its subsidiaries acute care hospitals, behavioral health facilities, and ambulatory centers nationwide. Founded in 1978, UHS subsidiaries now have more than 70,000 employees.
The Utilization Review Director will:
Preauthorize patient's treatment with network and non-network providers; this includes all Medicaid, Private Insurance, and Self Pay clients.
Ensure the UR plan meets requirements of regulatory and licensing groups
Perform the overall action of providing and ongoing, systematic process for the assessment of the necessity and efficiency of the use of Provo Canyon Behavioral Hospital services
Assist in the promotion and maintenance of high quality patient care through the review and evaluation of clinical practices
Manage communication with internal and external entities to facilitate acquisition of resources
Maintain an awareness of funding sources needs and status and initiates appropriate action
Case coordination will normally include prospective and retrospective review which includes, but is not limited to, prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and assuring quality cost effectiveness.
Supervise, plan and organize the functions of Provo Canyon Behavioral Hospitals case management system to minimize denials of payment
Manage, prepare and submit appeals to third party payers on clinical denials. Review payer contracts and regulatory requirements on an ongoing basis, update pertinent policies and procedures and trains staff on special requirements
Monitor patient progress toward desired outcomes through assessments and evaluations.
May arrange referrals, consultations, therapeutic services, and confer with other specialists on the course of care and treatment.
Conduct admission and concurrent reviews and communicates pertinent information to payer and treatment team when needed
Document all concurrent reviews and retrospective reviews in UM Binder.
Alert clinicians of any lack of needed UM documentation for priority completion.
Alert Nursing and Health Services Director of any abnormalities in the UM process.
Provide ongoing data entry in the Network Utilization Management MIDAS software System.
Provide timely communication, and assistance to the insured of denials and the appeal process.
Gather information and orchestrate needed MD to MD reviews in the UM process.: