Director of Utilization Management & Care Coordination

CommonSpirit Health; Houston (TX); On-site; USD 140,000 - 210,000; Full time

Job summary

CommonSpirit Health in Houston, TX, seeks a Director of Utilization Management to lead the development, implementation and evaluation of the UM program in support of the Care Coordination model. You will direct staff, drive operational performance, and ensure medical necessity determinations across authorizations, admissions and continued stay reviews.

The role requires strong leadership, experience in managed care, and a track record in policy development, compliance and accreditation.

Qualifications

• Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
• Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination).
• 5 years of progressively responsible management experience.
• Extensive operational experience in managed care; program planning, implementation, staff development, and needs assessment.
• Comprehensive knowledge of utilization management, financial management including revenue cycle, Medicare, Medicaid, and commercial admission and review requirements.

Responsibilities

• Develop strategies to achieve departmental and CommonSpirit Health goals and objectives.
• Direct UM staff to meet or exceed operational performance standards.
• Oversee development and implementation of UM policies, procedures and processes; support accreditation activities.
• Manage payer requirements, address denials effectively, and ensure compliance with payer and regulatory requirements.
• Review and analyze UM program outcomes and quality metrics.

Skills

Clinical management

Healthcare administration

Staff development

Program planning

Payer requirements

Education

Bachelor's in Nursing/Health Care Administration

Advanced clinical degree

Job description

CommonSpirit Health in Houston, TX, seeks a Director of Utilization Management to lead the development, implementation and evaluation of the UM program in support of the Care Coordination model. You will direct staff, drive operational performance, and ensure medical necessity determinations across authorizations, admissions and continued stay reviews.

The role requires strong leadership, experience in managed care, and a track record in policy development, compliance and accreditation.