Director, Utilization Management & Care Coordination

Mountain Region Support; United States; On-site; USD 150,000 - 190,000; Full time

Job summary

CommonSpirit Health is seeking an Utilization Management Director to lead the UM program, align with Care Coordination model, and translate organizational goals into departmental strategies that drive clinical excellence and operational outcomes.

You will oversee policies, regulatory compliance, payer requirements, and denials management; collaborate with division leadership and physicians; oversee inpatient reviews, continued stay assessments, retrospective authorizations, and appeals.

Qualifications

• Bachelor’s degree in Nursing, Health Care Administration or advanced clinical degree is required.
• Minimum of three (3) years of clinical case management (Utilization Management, Denial Management, Care Coordination).
• Five (5) years of progressively responsible management experience in managed care, revenue cycle, and regulatory compliance.

Responsibilities

• Provides overall direction, design, development, implementation, and monitoring of utilization programs to meet 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

Healthcare administration

Utilization management

Regulatory compliance

Denial management

Education

Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree

Master's degree in Nursing, Health Care Administration or related clinical field

Job description

CommonSpirit Health is seeking an Utilization Management Director to lead the UM program, align with Care Coordination model, and translate organizational goals into departmental strategies that drive clinical excellence and operational outcomes.

You will oversee policies, regulatory compliance, payer requirements, and denials management; collaborate with division leadership and physicians; oversee inpatient reviews, continued stay assessments, retrospective authorizations, and appeals.