Director, Utilization Management

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.