Director of Utilization Management & Care Coordination

CommonSpirit Health; Centennial (CO); On-site; USD 150,000 - 210,000; Full time

Job summary

CommonSpirit Health seeks an Utilization Management Director to lead the UM program, aligning with the Care Coordination model and guiding staff through inpatient reviews, continued stays, retrospective authorizations, and appeals.

You will ensure compliance with CMS, TJC, and payer requirements, monitor quality metrics, and drive policies to optimize denials reduction and value capture. Residency in CO, KS, or UT is preferred.

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; extensive experience in program planning, implementation, staff development, and needs assessment.
• Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements.

Responsibilities

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

Skills

Leadership

Data analytics

DRG knowledge

Cost containment

Education

Bachelor's degree in Nursing

Health Care Administration

RN license

Advanced clinical degree

Tools

Epic

Cerner

Meditech

Parigon

Job description

CommonSpirit Health seeks an Utilization Management Director to lead the UM program, aligning with the Care Coordination model and guiding staff through inpatient reviews, continued stays, retrospective authorizations, and appeals.

You will ensure compliance with CMS, TJC, and payer requirements, monitor quality metrics, and drive policies to optimize denials reduction and value capture. Residency in CO, KS, or UT is preferred.