[Hiring] Utilization Management Director @CommonSpirit Health

Role Description

As 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
• 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
• Maintaining regulatory compliance and accreditation standards
• Managing complex payer requirements
• Mitigating denials through proactive analysis
• Monitoring quality metrics and program outcomes

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
• Advancing the CommonSpirit Health mission through efficient, compliant, and patient-centered care coordination

Additional responsibilities include:

• Providing 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
• Assuring compliance with Federal, State, The Joint Commission (TJC), Det Norske Veritas (DNV), and other regulatory agencies and internal standards and requirements
• Managing programs that emphasize appropriate admissions, concurrent and retrospective review of care, and concurrent denials
• Collaborating with division and system leadership, revenue cycle, and other stakeholders to ensure achievement of denial reduction and value capture goals
• Analyzing and reporting significant utilization trends, patterns, and impact to appropriate departmental, Utilization Management, Revenue Cycle, Payer Strategy, and Clinical Joint Operating Committees
• Acting 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
• Providing 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.

Qualifications

• 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
• Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements

Requirements

• Master's degree in Nursing, Health Care Administration or related clinical field (preferred)
• Experience with data analytics to include cost containment, over/under utilization assessment and clinical outcomes (preferred)
• Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services (preferred)
• 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