Director, Utilization Review

Your experience matters:

At TGH Behavioral Hospital, we are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. Here, you're not just valued as an employee, but as a person. Joining our team, you're embracing a vital mission dedicated to making communities healthier. Join us on this meaningful journey where your skills, compassion, and dedication will make a remarkable difference in the lives of those we serve.

How you'll contribute 

The responsibility of the Utilization Review Director is to ensure the utilization review activities are completed accurately and timely. This includes the precertification and recertification, peer to peer process, and appeals. The UR Director will report consistently and accurately to the CEO or delegate the authorization status of current patients and appeals. The Director will ensure that all UR staff members follow department and facility procedures. The Director will further ensure that communication with all relevant departments, but especially CBO and Business Office, meets staff and patient needs. The UR Director will report consistently and accurately to the CEO or delegate the authorization status of current patients and appeals.

Responsibilities:

• Oversees the UR department, ensuring staff has completed all assignments and monitors performance.

• Ensures all pre-certifications are completed for inpatient and outpatient services.

• Ensures all re-certifications are completed for inpatient and outpatient services and reports status to the CEO or delegate.

• Assists with creation of treatment team agenda and participates to ensure team is aware of coverage info as well as collecting information for communication with insurance or other funding source.

• Be available to educate staff members from other relevant departments on documentation requirements / medical criteria and does so in a professional, organized, and understandable manner.

• Works with DON to ensure documentation requirements are met.

• Ensure appeals are completed thoroughly and on a timely basis.

• Interface with managed care organizations, external reviews, and other payers.

• Participates in Administrator on Call rotation.

• Communicate with physicians to schedule peer to peer reviews.

• Accurately report denials.

What we offer 

Fundamental to providing great care is supporting and rewarding our team. In addition to your base compensation, this position also offers:  

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health- savings accounts  

• Competitive paid time off and extended illness bank package for full-time employees 

• Income-protection programs, such as life, accident, critical-injury insurance, short- and long-term disability, and identity theft coverage 

• Tuition reimbursement, loan assistance, and 401(k) matching  

• Employee assistance program including mental, physical, and financial wellness 

• Professional development and growth opportunities

Qualifications and Requirements 

Applicants should possess the following qualifications and skills:

• Education: Bachelor's degree required. Master's degree preferred.

• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.

• License: Current unencumbered clinical license strongly preferred.

• Additional Requirements: CPI and CPR preferred within 30 days of hire. May be required to work flexible hours. 

• TGH Behavioral Hospital strives to maximize the health, function, and quality of life of those we serve through comprehensive physical medicine and rehabilitation programs. We are accredited by The Joint Commission and CARF-accredited for our Comprehensive Integrated Inpatient Rehabilitation Program and our Stroke and Brain Injury Specialty programs.

EEOC Statement

"TGH Behavioral Hospital is an Equal Opportunity Employer. TGH Behavioral Hospital is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment."

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.