Director Utilization Management

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

Job Summary and Responsibilities

The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics.

Job Requirements

Required:

• 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; 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.

Where You'll Work

Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area.