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Posted: Friday, December 29, 2017 12:06 AM


Job Description:

The Manager of Utilization Management is responsible for the oversight of utilization management processes for all applicable services at Hillside Family of Agencies, including mental health, substance abuse, and medical services. This position oversees referrals and treatment provision to our service recipients; coordinates with programs regarding the review of effectiveness of treatment interventions and/or modalities within the utilization process; ensuring levels of appropriate care, and oversees discharge planning process.

Essential Functions:

• Accountability for daily operations of UM review (prior authorization, concurrent review, discharge planning). Lead appeal of denials in partnership with the clinical team.
• Work with leadership to determine how current policies/practices will need to be modified in order to ensure effective utilization management under new Medicaid Managed Care requirements
• Supports cultural change associated with Medicaid Managed Care requirements and participates on the Medicaid Managed Care utilization management work group
Participates in the development, implementation and oversight of the utilization management process (workflows, tools, turnaround times, documentation, etc.)
• Establishes and manages key performance indicators (i.e., ALOS, denials, appeals, etc) to evaluate the agency’s utilization management process.
• Works with clinical leadership across the system of care to meet utilization targets and EMR documentation requirements. Provides regular feedback and coaching to clinical leadership.
• Ensures that care provided aligns with Hillside’s value measurement framework, regulations, clinical practice guidelines, medical necessity guidelines, and utilization standards
• Supervises staff performing utilization management functions and the Certified Coding Specialist; provides UM training as needed.
• Conducts case record review audits for compliance with UM standards and conducts inter-rater reliability assessment of UM staff
• Leads utilization review meetings and case conferences with integration staff and clinicians on a regular basis. Consults to make determinations on exceptional cases prior to all denials of care.
• Ensures compliance with regulatory and payer requirements and documentation requirements for utilization management.
• Communicates with UM counterparts at contracted managed care organizations. Acts as a liaison and facilitates consultation with managed care organizations as needed (i.e., doc-to-doc).
• May have on-call responsibilities:

Job Requirements


• Bachelors required in Social Work, Nursing or related fields; Masters preferred.


• 5-7 years of clinical experience such as direct care, care coordination or case management in a behavioral health system or public or private healthcare setting.
• Prior utilization review experience of 1-3 years in a clinical or managed care setting required.
• Experience with children’s’ services preferred.

Contact Person: Melissa O'Neill
Email Address:
Apply URL:

Job Duration: Indefinite
Min Education: BA/BS/Undergraduate
Min Experience: 5-7 Years

• Location: Rochester, Rochester, NY

• Post ID: 33458047 rochester is an interactive computer service that enables access by multiple users and should not be treated as the publisher or speaker of any information provided by another information content provider. © 2018