Director of Utilization Management

The Director of Utilization Management will oversee all utilization-related functions, ensuring clinical care, regulatory requirements, and payer expectations are aligned while optimizing throughput and revenue integrity.

Reporting Structure:

1. Reports to: Executive Leadership (VP of Revenue Cycle or Interim Executive in that role)
2. Works closely with: CMO, CHRO, Medical Staff leadership, Nursing leadership, Compliance, and Quality

Essential Functions:

Leadership & Strategy

1. Establish and lead the Department of Utilization Management
2. Develop standardized policies, workflows, and escalation pathways
3. Align department objectives with hospital strategic goals

Operational Oversight

1. Direct oversight of Case Management, UR, CDI, Denials, and P2P functions
2. Ensure timely authorizations, reviews, and appeals
3. Optimize staffing models and coverage

Physician & Clinical Engagement

1. Partner with physicians on medical necessity and documentation standards
2. Oversee peer-to-peer preparation and escalation
3. Support Medical Staff education related to utilization and payer expectations

Financial & Regulatory Accountability

1. Reduce avoidable denials and excess length of stay
2. Ensure compliance with CMS, Joint Commission, and payer requirements
3. Monitor utilization, quality, and financial performance metrics

Data & Reporting

1. Develop dashboards and routine reporting for executive leadership
2. Identify trends, risks, and opportunities for improvement
3. Lead continuous performance improvement initiatives

Other Duties

Minimum Education/Certifications

1. RN, MD, DO, or other clinically licensed professional (required)
2. Bachelor's degree required; Master's degree preferred (MBA, MHA, MSN)

Minimum Work Experience

1. 5-10 years of progressive experience in utilization management, case management, or revenue integrity
2. Strong working knowledge of CMS regulations, payer criteria, and denial management
3. Demonstrated leadership and change-management experience