Director Utilization Management

Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.

Under the direction of the Vice President of Revenue Cycle, the Director of Utilization Management provides strategic and operational leadership for utilization management activities across a network of hospitals. Oversee contracted utilization management vendors and collaborates with physicians, Physician Advisors, CDI, Case Management, Revenue Cycle, Compliance, and Finance to ensure appropriate status determination, medical necessity compliance, denial prevention, and reimbursement optimization. Identifies opportunities and develops strategies that improve quality, efficiency, compliance, and financial performance.

Essential Job Functions

• Provides strategic oversight of system-wide utilization management programs to optimize reimbursement, regulatory compliance, patient status determination, and resource utilization.
• Directs and evaluates contracted utilization management vendor performance, including productivity, quality, staffing, contractual compliance, and operational improvement initiatives.
• Develops and implements utilization management policies, workflows, and best practices across the healthcare network.
• Oversee medical necessity review processes, denial prevention strategies, payer audit support, and appeals management activities.
• Partners with Physician Advisors, CDI, and operational leaders to improve documentation quality, status determination accuracy, observation management, and length-of-stay performance.
• Collaborates with Revenue Cycle leadership to identify and implement opportunities that improve reimbursement and reduce avoidable denials.
• Develops and oversees utilization management analytics, dashboards, scorecards, and key performance indicators to support data-driven decision-making.
• Analyzes utilization trends, financial outcomes, and operational performance to identify system-wide improvement opportunities.
• Ensures compliance with CMS, Medicare, Medicaid, commercial payer requirements, InterQual, MCG, and accreditation standards.
• Build collaborative relationships with physicians, clinical leaders, and operational departments to promote organizational goals and performance improvement.
• Provides education and consultative support regarding medical necessity, documentation requirements, utilization management regulations, and payer expectations.
• Performs similar or related duties as requested or directed.

Education:

• 4 Year / Bachelor's Degree In Nursing (BSN), required
• Master's Degree In one of the following preferred:
  • Nursing (MSN)
  • Healthcare Administration (MHA)
  • Business Administration (MBA)

Experience:

• Minimum 7 years of combined experience required in:
  • Utilization Review
  • Case Management
• Minimum 5 years of experience in progressive healthcare leadership; multi-hospital and vendor oversight preferred

Licensure/Certifications:

• NYS Licensure as a Registered Nurse (RN) required
• ACM - Accredited Case Manager preferred
  CCM - Certified Case Manager preferred
  CMAC - Case Management Administrator Certification peferred

Skills:

• Attention to Detail
• Build Relationships
• Communication
• Computer Skills
• Critical Thinking
• Analysis & Evaluation
• Data Management
• Decision Making
• Leadership
• Manage People
• Multi-Tasking
• Maintain Confidentiality
• Employee Relations
• Reading/Writing/Comprehension
• Systems Thinking
• Strategic Thinking
• Recognize Problems
• Quality Assurance

Physical Requirements:

• Sedentary Work - Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking or standing are required only occasionally, and all other sedentary criteria are met.
• Occasional repetitive motion
• Frequent hearing, and talking
• Constant Typing/ Clerical/ Dexterity and Seeing/ Monitor/ Computer Use

Travel:

• Occasional Travel - The job may require travel from time- to-time, but not on a regular basis.