Utilization Review Manager (Orange County)
Surge Billing Solutions, Orange, CA, United States
Position Summary
The Utilization Review Manager l optimizes our UM operations including clients in Substance Abuse, Mental Health, and Eating Disorder treatment facilities serving both Adult and Adolescent populations. This role is critical in ensuring effective utilization review processes, maximizing treatment authorizations and length of stay, improving clinical and financial outcomes, and driving the strategic development of the UM department.
The Utilization Review Manager functions, including documentation auditing, clinical collaboration with partner facilities, process improvement initiatives, payer communications, peer review consultations, and appeals.
Key Responsibilities
Partner with clinical and medical staff at facilities to improve documentation, medical necessity reviews, and authorization approvals.
Conduct and/or oversee peer reviews and collaborate with insurance carriers on outcomes and appeals management.
Monitor, evaluate, and refine UM processes to maximize authorized treatment days and enhance quality of care.
Develop, implement, and manage systems and workflows to support UM efficiency and compliance. Schedule, track, and manage utilization management reviews across facilities.
Coordinate and maintain effective payer communications, ensuring timely responses and accurate submissions.
Audit clinical documentation to ensure compliance with payer requirements and regulatory standards.
Provide strategic advisement on department growth, scalability, and operational excellence.
Adhere to tracking performance metrics and KPIs to evaluate department success and identify areas for improvement.
Qualifications
Experience in utilization management within behavioral healthcare.
Extensive knowledge of payer requirements, clinical criteria (ASAM, LOCUS, InterQual, MCG), and behavioral health treatment modalities.
Strong knowledge of revenue cycle management in behavioral healthcare settings.
Excellent communication, negotiation, and collaboration skills for interacting with payers, clinical teams, and leadership.Demonstrated expertise in process management, systems analysis, and compliance oversight.
Core Competencies
Strategic Leadership & Vision
Clinical & Regulatory Expertise
Problem-Solving & Analytical Thinking
Effective Communication & Negotiation
Operational Excellence & Process Improvement
Team Development & Mentorship
Physical Requirements / Work Environment
Primarily sedentary, involving computer work and phone communication
Ability to work occasional evenings or weekends depending on department needs
Benefits:
Dental insurance
Health insurance
Paid time off
Vision insurance
Application Question(s):
Do you have experience in Authorizations/Utilization Management for Inpatient/Outpatient Behavioral Healthcare facilities (SUD/MH/ED)?
Work Location: Remote
The Utilization Review Manager l optimizes our UM operations including clients in Substance Abuse, Mental Health, and Eating Disorder treatment facilities serving both Adult and Adolescent populations. This role is critical in ensuring effective utilization review processes, maximizing treatment authorizations and length of stay, improving clinical and financial outcomes, and driving the strategic development of the UM department.
The Utilization Review Manager functions, including documentation auditing, clinical collaboration with partner facilities, process improvement initiatives, payer communications, peer review consultations, and appeals.
Key Responsibilities
Partner with clinical and medical staff at facilities to improve documentation, medical necessity reviews, and authorization approvals.
Conduct and/or oversee peer reviews and collaborate with insurance carriers on outcomes and appeals management.
Monitor, evaluate, and refine UM processes to maximize authorized treatment days and enhance quality of care.
Develop, implement, and manage systems and workflows to support UM efficiency and compliance. Schedule, track, and manage utilization management reviews across facilities.
Coordinate and maintain effective payer communications, ensuring timely responses and accurate submissions.
Audit clinical documentation to ensure compliance with payer requirements and regulatory standards.
Provide strategic advisement on department growth, scalability, and operational excellence.
Adhere to tracking performance metrics and KPIs to evaluate department success and identify areas for improvement.
Qualifications
Experience in utilization management within behavioral healthcare.
Extensive knowledge of payer requirements, clinical criteria (ASAM, LOCUS, InterQual, MCG), and behavioral health treatment modalities.
Strong knowledge of revenue cycle management in behavioral healthcare settings.
Excellent communication, negotiation, and collaboration skills for interacting with payers, clinical teams, and leadership.Demonstrated expertise in process management, systems analysis, and compliance oversight.
Core Competencies
Strategic Leadership & Vision
Clinical & Regulatory Expertise
Problem-Solving & Analytical Thinking
Effective Communication & Negotiation
Operational Excellence & Process Improvement
Team Development & Mentorship
Physical Requirements / Work Environment
Primarily sedentary, involving computer work and phone communication
Ability to work occasional evenings or weekends depending on department needs
Benefits:
Dental insurance
Health insurance
Paid time off
Vision insurance
Application Question(s):
Do you have experience in Authorizations/Utilization Management for Inpatient/Outpatient Behavioral Healthcare facilities (SUD/MH/ED)?
Work Location: Remote