Utilization Review Senior Manager Job at Walker Health Services in Baltimore

Job Title: Utilization Review Manager

Job Summary:

Walker Health Services is seeking an experienced and strategic Utilization Review Manager to lead our Utilization Review (UR) department. This individual will be responsible for overseeing the UR process, ensuring compliance with state-specific guidelines, and developing policies and procedures for both internal workflows and client interactions. The Manager will also focus on optimizing UR operations, managing the team, and ensuring that all authorizations and reviews meet payer requirements.

Key Responsibilities:

• Team Leadership: Lead and manage the Utilization Review team, providing guidance, mentorship, and professional development opportunities.
• Policy Development:
  • Develop and implement internal policies and procedures to streamline the UR process and ensure consistency and efficiency.
  • Establish clear protocols for clients to follow when submitting documentation and clinical information.
• State-Specific Compliance:
  • Ensure all UR processes align with state-specific authorization requirements.
  • Regularly review and update state-specific guidelines to reflect changes in payer policies.
• Client Relationship Management:
  • Work closely with clients to educate them on state-specific authorization requirements and the necessary documentation for timely approvals.
  • Provide clients with ongoing support to improve their understanding of the UR process, minimizing authorization denials and delays.
• Process Oversight:
  • Oversee the review of patient admissions, clinical information, and authorizations, ensuring all reviews are conducted correctly.
  • Monitor team performance, ensuring timely completion of all UR tasks and maintaining a high level of accuracy.
• Reporting and Analytics:
  • Provide senior management with regular reports on UR performance, identifying trends, challenges, and areas for process improvement.
• Cross-Departmental Collaboration:
  • Collaborate with the billing and management teams to ensure seamless coordination of the UR process and to support the organization’s broader operational goals.
  • Act as the primary point of contact for insurance companies and internal personal on complex or escalated cases.
  • Lead quarterly client reviews to discuss UR performance, process improvements, and any upcoming changes.

Requirements:

• 5+ years of experience in Utilization Review, Substance Abuse, or Mental Health fields, with at least 2 years in a leadership role.
• Deep understanding of state-specific authorization guidelines and regulations, particularly in the mental and behavioral health sectors.
• Proven ability to lead and manage a team, with a strong focus on mentorship and professional development.
• Excellent communication and relationship management skills, with the ability to educate and guide clients in navigating the UR process.
• Proficiency with electronic medical record systems (e.g., Kipu, Alleva) and billing processes.
• Ability to work independently, manage multiple priorities, and meet deadlines in a fast-paced environment.

Location:

• Hybrid role, with a need to commute to Pikesville, MD 21208.