Job Summary and ResponsibilitiesAs our Utilization Management (UM) Director, you will serve as the strategic leader responsible for the development, implementation, and oversight of the Utilization Management program. In alignment with the CommonSpirit Health Care Coordination model, you will provide expert direction to our staff while overseeing critical workflows, including inpatient admission reviews, continued stay assessments, retrospective authorizations, and the management of appeals. By collaborating closely with the Division Director of Care Coordination, you will translate high-level organizational goals into actionable departmental strategies that drive excellence in clinical care and operational outcomes.
Every day you will lead a high-performing team tasked with meeting and exceeding operational performance standards. Your daily responsibilities will include overseeing the development and refinement of UM policies, procedures, and internal processes to ensure peak efficiency. You will play a vital role in maintaining regulatory compliance and accreditation standards, managing complex payer requirements, and mitigating denials through proactive analysis. By monitoring quality metrics and program outcomes, you will ensure our department remains responsive to the needs of the healthcare system while maintaining the highest standards of medical necessity determination.
To be successful in this role, you will possess proven leadership competencies in healthcare administration, utilization management, and the ability to cultivate strong, ethical partnerships with physicians and clinical teams. We are seeking a mission-driven expert committed to navigating evolving payer landscapes, leveraging data to optimize quality outcomes, and advancing the CommonSpirit Health mission through efficient, compliant, and patient-centered care coordination.
- Provides overall direction, design, development, implementation, and monitoring of utilization programs to meet the Care Coordination goals and market utilization management goals while maintaining stakeholder satisfaction.
- Assures compliance with Federal, State, The Joint Commission (TJC), Det Norske Veritas (DNV), and other regulatory agencies and internal standards and requirements.
- Manages programs that emphasize appropriate admissions, concurrent and retrospective review of care, and concurrent denials.
- Collaborates with division and system leadership, revenue cycle, and other stakeholders to ensure achievement of denial reduction and value capture goals.
- Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental, Utilization Management, Revenue Cycle, Payer Strategy, and Clinical Joint Operating Committees.
- Acts as a resource to the medical staff, administrative staff, divisional staff, as well as external regulatory agencies in all issues relating to utilization management within the CommonSpirit Health market.
Regional Oversight: Provides strategic leadership for Utilization Management programs across Colorado, Kansas, and Utah. Please note that this position requires residency in one of these three states to facilitate collaboration and market-level support.
Job Requirements
Required
- Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
- Minimum of three (3) years of clinical case management (Utilization Management, Denial Management, Care Coordination).
- Five (5) years of progressively responsible management experience Extensive operational experience in managed care; extensive experience in program planning, implementation, staff development, and needs assessment.
- Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements.
Preferred
- Master's degree in Nursing, Health Care Administration or related clinical field.
- Experience with data analytics to include cost containment, over/under utilization assessment and clinical outcomes.
- Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services.
- Current unrestricted RN license where practicing required. National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within two (2) years upon hire.
- Able to apply clinical guidelines to ensure progression of care. Communicate effectively in writing and verbally.
- Ability to actively work within multiple electronic health records (Epic, Cerner, Meditech, and/or Parigon).
- Understand how utilization management and case management programs integrate.
- Knowledge of CMS standards and requirements.
