The Director, Utilization Management is reponsible for direct supervision of Utilization Review nursing staff: Onsite and telephonic review including discharge planning activities and case management to include tracking and trending inpatient and outpatient utilization, provider corrective action for utilization trends that have variances and reporting the UM statistical data to the Medical Director. Direct supervision of the Retrospective review and Appeals team: including tracking and trending types of retrospective reviews and appeals, overturns, fair hearing and IRO results and assuring turnaround times are met. Responsibilities also include compliance with THHSC regulations for conveying adverse determinations decisions to Community Health Choice (Community) provid
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