Overview

The Director of Utilization Management (UM) provides enterprise-wide leadership over medical necessity and level-of-care (LOC) processes, including authorization standards, escalation pathways, and payor engagement to support clinical throughput and revenue integrity. This leader is accountable for end-to-end UM execution - admission, concurrent, and retrospective review; exception management; and peer-to-peer (P2P) coordination, grounded in evidence-based criteria and regulatory/accreditation requirements, while driving clinical denial prevention and recovery. The Director partners with Physician Advisors, Care Management (CM), Quality, CDI, and other Revenue Cycle leaders to reduce avoidable denials and length of stay (LOS)-related avoidable days, improve payor outcomes, and drive performance, compliance, and enterprise standardization.
Qualifications

Education: Bachelor's degree in Nursing (BSN) required.
• Master's degree preferred.
• Experience: Minimum of 7 to 10 years of progressive healthcare experience, including utilization management experience.
• Minimum of 3 to 5 years of leadership experience managing teams, programs, or enterprise-level initiatives.
• License/Certification/Registration:

• Active Registered Nurse (RN) license required.
• Preferred certifications include:
  • ACM (Accredited Case Manager)
  • CCM (Certified Case Manager)
  • CMAC (Case Management Administrator Certification)
  • CPHQ (Certified Professional in Healthcare Quality)
  • Other related utilization management, case management, or quality credentials

• Demonstrated strategic, enterprise-level decision-making ability that balances:

• Quality of patient care
• Regulatory compliance
• Financial stewardship
• Organizational goals

• Proven experience in:

• Team leadership and talent development
• Staff coaching and mentoring
• Building high-performing teams

• Executive-ready communication skills, including:

• Written communication
• Verbal communication
• Facilitation and presentation skills
• Executive stakeholder engagement

• Strong change leadership capabilities with a continuous improvement mindset.
• Demonstrated performance management discipline, including:

• Key Performance Indicators (KPIs)
• Operational cadence
• Accountability frameworks

• Proven ability to influence and align stakeholders across:

• Clinical operations
• Case management
• Utilization management
• Revenue cycle operations
• Executive leadership

• Deep expertise in:

• Medical necessity determinations
• Level of Care (LOC) criteria
• Observation versus inpatient status reviews
• Two-Midnight Rule requirements
• Utilization management best practices

• Extensive experience with:

• Prior authorization operations
• Concurrent review processes
• Utilization review workflows
• Denial prevention strategies

• Working knowledge of:

• Diagnosis-Related Groups (DRGs)
• ICD-10-CM coding
• ICD-10-PCS coding
• Healthcare reimbursement methodologies
• Revenue cycle principles

• Strong compliance leadership capabilities, including the ability to translate regulatory and accreditation requirements into operational practice, including:

• CMS Conditions of Participation (CoPs)
• The Joint Commission standards
• Audit readiness requirements
• Regulatory compliance expectations

• Expertise in utilization and throughput analytics, including:

• Length of Stay (LOS) drivers
• Avoidable days analysis
• Denial trends
• Resource utilization review
• Performance reporting

• Proficiency with:

• Utilization management technologies
• Reporting and analytics tools
• Operational dashboards
• Performance monitoring systems

• Strong payor relationship management skills, including:

• Escalation management
• Negotiation support
• Resolution of authorization and medical necessity disputes

• Demonstrated experience collaborating with:

• Physician Advisors
• Payers
• Case Management teams
• Clinical teams
• Revenue Cycle stakeholders
• Operational leadership

• Strong analytical, organizational, leadership, and problem-solving skills with a focus on quality outcomes, regulatory compliance, utilization management excellence, and financial performance.