Utilization Management Director

Sample Position Description

Position Title: Utilization Management Director
Immediate Superior: Chief Financial Officer or Other Senior Executive
General Purpose: The Utilization Management Director is responsible for administering and managing the facilitys
utilization management program.
Responsibilities:

Develops and implements the organizations utilization management plan in accordance with the mission and
strategic goals of the organization, federal and state law and regulations, and accreditation standards

Develops and implements systems, policies and procedures for prospective, concurrent and retrospective case
review, clinical practice guidelines, care maps, clinical protocols, and reporting quality of care issues identified
during the utilization review process

Educates and trains the leadership, staff, and business associates as to the utilization management plan and their
respective responsibilities relative to the plan

Collects, analyzes, and maintains data on the utilization of medical services and resources

Prepares and presents quarterly utilization management summaries to the Board, identifying potential areas for
improvement

Reports quality of care issues identified during the utilization review process according to policy and procedure

Acts as the liaison to the Peer Review Organization (PRO), performing duties such as the preparation of replies to
PRO denials

Obtains pre-approval or pre-certification from third-party payers for procedures and continued stay

Actively participates or facilitates selected committees such as Utilization Management and Performance
Improvement

Qualifications:

A bachelors degree in a clinical or allied health field

RHIA or RHIT credential or licensure as a RN preferred

A minimum of three years experience in utilization management, health information management, nursing, quality
improvement, or a related field

Knowledge of statistics, data collection, analysis, and data presentation

Excellent interpersonal communication and problem-solving skills

Knowledge of utilization management techniques

Knowledge of ICD and CPT coding