Position Summary
The Utilization Review (UR) Clinical lead serves as a subject matter expert in utilization management and hospital revenue cycle operations. This role partners directly with large hospital systems to assess, optimize, and support utilization review and denial management initiatives.
The ideal candidate is a licensed clinician with strong IP utilization review experience and the ability to work directly with executive and operational leaders within healthcare organizations. This position requires a consultative mindset, excellent communication skills, and the ability to influence change while driving measurable outcomes for clients.
Essential Responsibilities
- Serve as the primary clinical consultant for assigned hospital and health system clients.
- Build and maintain strong relationships with client leadership, including Case Management Directors, Revenue Cycle Leaders, Physician Advisors, and C-suite executives.
- Conduct assessments of utilization review processes and identify opportunities for operational improvement.
- Provide strategic recommendations to improve authorization processes, reduce denials, and optimize reimbursement.
- Facilitate client meetings, present findings, and communicate project updates to stakeholders.
- Support implementation of process improvements and monitor performance metrics.
- Review inpatient and outpatient utilization management processes for compliance and efficiency.
- Analyze denial trends, payer behavior, and utilization patterns.
- Collaborate with physician advisors and operational teams to improve medical necessity documentation and appeal success rates.
- Provide guidance on CMS, Medicare, Medicaid, and commercial payer requirements.
- Assist clients with length-of-stay management, authorization processes, and denial prevention strategies.
- Develop and implement best practices related to utilization management and revenue integrity.
- Educate client teams on regulatory changes, payer requirements, and industry best practices.
- Develop training materials, workflows, and standard operating procedures.
- Mentor and support internal consultants and clinical team members.
- Serve as a subject matter expert during client engagements and business development opportunities.
Experience
- Minimum of 7 years of IP Utilization Review, Case Management or Revenue Cycle experience.
- Minimum of 3 years working directly with hospital systems in a consulting or client-facing capacity.
- Strong understanding of:
- Hospital revenue cycle operations
- Utilization management
- Denial management
- Medical necessity criteria
- Payer regulations and reimbursement methodologies
- Experience presenting in executive leadership and facilitating client meetings.
Knowledge & Skills
- Strong knowledge of Medicare, Medicaid, and commercial payer requirements.
- Experience with electronic medical records, preferably Epic.
- Excellent presentation and communication skills.
- Ability to build credibility and influence stakeholders at all levels.
- Strong analytical and problem-solving abilities.
- Self-directed with the ability to manage multiple client engagements simultaneously.
- Proficiency in Microsoft Office applications, particularly Excel and PowerPoint.
Qualifications
Education
- Registered Nurse (RN) required; BSN preferred.
- Advanced degree (MSN, MHA, MBA) preferred.
Licensure
- Active, unrestricted RN license required.
Travel Requirements
- Up to 25% travel, as required by client engagements.
