Director, Utilization Review & Denials Strategy

Baylor Scott & White Health

Columbus (OH)

On-site

USD 180,000 - 240,000

Full time

14 days+

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Job summary

Baylor Scott & White Health in Columbus, OH seeks a Director of Utilization Review to lead UR strategy across the system. You will oversee policies, concurrent and retrospective reviews, and align with CMS and payer requirements to optimize outcomes and reduce denials.

Reporting to the Senior VP of Revenue Cycle, you will partner with clinical and operational leaders, develop metrics, and drive process improvements through Epic and related tools to enhance efficiency and financial performance.

Qualifications

Bachelor's degree in nursing or related field.
5+ years of nursing or utilization review experience.
1+ year in a leadership role.
RN license.
Proficiency with Epic; XSOLIS experience preferred.
Ability to collaborate with senior leaders across the organization.
Knowledge of InterQual or equivalent criteria for hospital admission.
Experience collaborating across departments in a large healthcare system.
Strong problem-solving, communication, and presentation skills.
Innovative UR processes via Epic, AI tools, and process improvement.

Responsibilities

Lead strategic and operational plans for utilization management aligned to BSWH objectives.
Direct daily UR operations and develop UR policies and processes.
Develop metrics and executive reporting for senior leadership and medical staff.
Partner with Physician Advisors and regional leadership to improve outcomes and utilization.
Streamline workflows, reduce redundancies, and improve employee experience.
Reduce payer denials and optimize the appeals process.
Oversee external vendors and remote/global resources.
Ensure CMS, Joint Commission, and payer compliance.