Acute Care Utilization & Compliance Leader

Southeast Georgia Health System Inc / SGHS; Brunswick (GA); On-site; USD 90,000 - 130,000; Full time

Job summary

Southeast Georgia Health System Inc / SGHS is seeking a leader to manage the Utilization Review program, ensuring accurate patient status and regulatory compliance. You will supervise UR staff and collaborate with physicians, PSOs, Case Management, Coding, CDI, and Revenue Cycle teams to optimize care levels and reimbursement.

Role requires directing reviews using InterQual/MCG criteria, monitoring payer requirements, reducing denials, and guiding policy development and staff education for

Qualifications

• RN with strong regulatory knowledge and payer policy understanding.
• Experience leading UR teams and collaborating with clinicians.
• Familiar with evidence-based criteria and CMS requirements.

Responsibilities

• Plan, organize, and lead the Utilization Review program and staff.
• Direct concurrent medical necessity reviews using InterQual/MCG criteria.
• Ensure regulatory compliance and optimal reimbursement pathways.
• Monitor denials, educate staff, and partner with Revenue Cycle teams.
• Develop policies, metrics, and budgets for the UR department.

Skills

Leadership

Regulatory compliance

Healthcare payer policy

Team supervision

Education

Registered Nurse (RN)

Tools

InterQual

MCG

CMS Guidelines

Job description

Southeast Georgia Health System Inc / SGHS is seeking a leader to manage the Utilization Review program, ensuring accurate patient status and regulatory compliance. You will supervise UR staff and collaborate with physicians, PSOs, Case Management, Coding, CDI, and Revenue Cycle teams to optimize care levels and reimbursement.

Role requires directing reviews using InterQual/MCG criteria, monitoring payer requirements, reducing denials, and guiding policy development and staff education for