Director of Utilization Review

The Director of Utilization Review manages the day-to-day operations of our Utilization Review (UR) department. You will lead a team that tracks authorized care, monitors lengths of stay, and ensures that clinical documentation supports medical necessity. You act as the main bridge between our clinical staff, medical providers, and external insurance payers.

Key Responsibilities

• Lead the daily work of the utilization review team and monitor the use of hospital services.
• Direct concurrent, continued stay, and retrospective medical record reviews.
• Work to prevent avoidable claim denials and handle clinical appeals and peer-to-peer reviews.
• Partner with physicians, therapists, nursing staff, and the revenue cycle team to prevent delays in care and support proper reimbursement.
• Keep the department aligned with state, federal, accreditation, and insurance payer rules.
• Monitor the appropriateness of hospital admissions and extended hospital stays.
• Prepare and submit appeals to third party payors.
• Manage hiring, training, mentoring, and performance management for UR staff.

• Active clinical license (RN, LCSW, LMFT, LPC) required.
• Minimum five (5) years of experience in healthcare utilization management/review, preferably in a behavioral health setting.
• Minimum three (3) years of supervisory or management experience required.
• Strong understanding of medical necessity criteria and local insurance payer guidelines.