Center for Discovery

  • Director of Utilization Review

    Job Locations US-CA-Los Alamitos
    Posted Date 2 weeks ago(7/6/2018 6:05 PM)
    Job ID
    # of Openings
    Job Type
    Regular Full-Time
  • Overview

    About Center For Discovery

    Center For Discovery has a 20-year legacy of transforming lives by promoting health, healing and hope to our clients and their families.  We are a national leader in behavioral healthcare and offer world-class treatment for eating disorders, mental health and substance abuse conditions.  We serve adolescents and adults in both residential and outpatient settings. It is our mission to create a transformative therapeutic experience aimed at profoundly and creatively facilitating behavioral, emotional and spiritual growth.  We place a high priority on providing an environment that supports an unlimited capacity for learning, and we seek qualified individuals who share our passion for improving the lives of those we serve.


    The Position

    The Director of Utilization Review coordinates all aspects of the company’s utilization review process to ensure that every patient receives quality care through utilization of adequate resources in the most cost-effective manner. The Director serves as the utilization liaison between treatment team and different payers. The individual in this position has overall responsibility for utilization performance improvement, denied authorizations, and operational management of the Utilization Review Department in order to promote effective utilization of resources. The position entails coordinating and managing concurrent and retrospective reviews of all patient’s medical records over the continuum of care.

    The Director of Utilization Review works closely with the physicians, nursing and clinical departments to ensure quality of documentation of patient care. The Director implements and manages the Utilization Management Plan and identifies trends that impact service delivery for quality improvement. The Director manages admission, concurrent and peer review as well as denials and appeals. The Director ensures cases are reviewed and responded to in a timely and clinically sound manner in accordance with policies and procedures. The Director implements and manages the Utilization Management Plan and identifies trends which impact service delivery for quality improvement including reasons for denials at a certain LOC, LOS impact, trending by Physician, insurances, financial impact, and appeals.



    • Extensive knowledge of the treatment of eating disorders, mental health disorders and substance abuse in children, adolescents and adults.
    • An in-depth understanding of levels of care and relevant criteria.
    • Current or past experience in providing utilization review, insurance authorization and an ability to advocate strongly for clients to receive appropriate levels of care.
    • Strong writing skills and experience in preparing formal written appeals.
    • Familiarity with the managed care system, benefit eligibility and appeals processes.
    • A working understanding of medical complications associated with eating disorders, mental illness and substance abuse and the ability to articulate medical necessity at all levels of care.
    • An advanced degree and/or certification in mental health or nursing related field.


    • Oversee staff operations, business planning, and ensure services are in compliance with professional standards, JCAHO, state and federal regulatory requirements.
    • Apply utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review.
    • Oversee Communication to third-party payers for initial and concurrent clinical review.
    • Review patient chart to ensure patient continues to meet medical necessity
    • Document actions and information shared with care team members or third-party payer
    • Provide ongoing clinical documentation trainings to ensure charts are aligned with insurance company guidelines.
    • Collect data on variances in LOC, lost days, costs/barriers to discharge/transition and denied days
    • Train and oversee staff on preparing appeals on denied cases when appropriate
    • Perform, train and oversee staff on completing peer reviews when required by third party payer, consulting with medical director, clinical director,  and other staff as appropriate
    • Review all aspects of care, ensuring optimal length of stay
    • In-depth knowledge of medical terminology, ASAM dimensions, and utilization review
    • Review the effectiveness of the comprehensive interface with external reviewers, communicate with external reviewers and managed care organizations to assure timely and appropriate interactions, monitor outcomes of reviews and provide consultation as needed.
    •  Review the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness.
    • Develop goals and objectives; policies and procedures related to the operational needs of the programs scenarios.
    • Maintain an active involvement and awareness of all patient admissions, discharges and transfers.
    • Assure that hiring, disciplinary actions and termination procedures are conducted in accordance with company policies.
    • Involve appropriate facility management in all decisions and review these decisions with COO prior to implementation.
    • Assure adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate.
    • Assure adequate orientation for new employees of the UR Case Management Department.
    • Provide for educational needs and professional development of staff.
    • Ensure an adequate system of communication and reporting is maintained between all staff members, as well as other departments involved in the ongoing operation of the program.
    • Conduct department meetings on a regular basis.
    • Coordinate the collection of outcome data within the company deadline.
    • Develop and implement a Performance Improvement tracking system, evaluate the results monthly, and report results to the Monthly Operational Review meetings in a timely manner.
    • Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem solving actions.
    • Demonstrate a professional attitude and supports the objectives of the facility philosophy through internal and external communications and interactions with all levels of staff, patients, community and referral sources.
    • Support facility-wide quality/performance improvement goals and objectives.


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