Executive Director, Utilization Management

Beth-Israel-Lahey-Health; Boston (MA); On-site; USD 180,000 - 210,000; Full time

Job summary

Beth Israel Lahey Health in Boston seeks an Executive Director of Utilization Management to lead enterprise-wide UM strategy, centralize operations, and align with payer requirements.

This senior role oversees standardizing policies, improving length of stay, and partnering with CMOs, physicians, and nursing leadership to ensure clinically appropriate and financially optimized care across all facilities.

Qualifications

• Bachelor’s degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field is required.
• Master’s degree strongly preferred.
• Active RN license preferred.
• Experience in Utilization Management, Case Management, or Revenue Cycle Operations is required.

Responsibilities

• Provide strategic and operational leadership for enterprise Utilization Management across all BILH facilities.
• Lead the transformation from decentralized to centralized UM with standardized processes.
• Develop and execute comprehensive utilization management strategies.
• Ensure CMS Conditions of Participation compliance and payer requirements.
• Oversee vendor partnerships and technology solutions (InterQual, MCG, etc.).
• Lead education and engagement of clinical leadership to reduce unnecessary admissions and length of stay.

Skills

Executive leadership

Strategic planning

Change management

Communication

Analytical skills

Vendor management

Epic EHR

Education

Bachelor’s degree in nursing/healthcare

Master’s degree preferred

Tools

Epic EHR

InterQual

MCG

Job description

Charlestown, MA • Beth Israel Lahey Health • Full-time • DayWhen you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.The Executive Director of Utilization Management (UM) provides strategic and operational leadership for the enterprise UM program across all Beth Israel Lahey Health (BILH) facilities. This role will lead the transformation of UM operations from a decentralized model to an integrated, centralized enterprise function with standardized processes, shared best practices, and consistent performance across all facilities. This executive-level position is responsible for developing and executing comprehensive utilization management strategies that ensure appropriate care delivery in the most clinically and financially optimal settings while maintaining regulatory compliance and optimizing reimbursement. The Executive Director partners with senior clinical and operational leaders, including the Chief Nursing Officers, Chief Medical Officers, Physician Advisors, and payer partners, to align UM initiatives with organizational goals of care coordination, length of stay optimization, and denial prevention while managing UM directors and staff across the system.Job Description:Essential Duties & Responsibilities, including but not limited to:Strategic Leadership & Program Development:Develop and execute enterprise-wide UM strategic plans aligned with BILH's clinical, financial, quality, and population health objectivesLead the evaluation, selection, and management of UM vendor partnerships and technology solutions, including InterQual, MCG, or other medical necessity criteria platformsDesign and operationalize standardized UM policies, procedures, and best practices across all BILH facilities, leading the transition from decentralized site-based operations to an integrated enterprise model while ensuring compliance with CMS Conditions of ParticipationServe as executive sponsor for the Utilization Management Committee and lead the annual review and implementation of the system-wide Utilization Management PlanDrive innovation in care coordination models that support value-based care initiatives and alternative payment modelsEstablish strategic payer relationships to optimize authorization processes and reduce administrative burdenEnterprise Integration & Standardization:Lead the strategic evolution of UM operations from facility-based models to a centralized, standardized enterprise functionAssess current state UM practices across all 15 hospitals to identify opportunities for standardization, efficiency gains, and best practice adoptionDevelop and implement a comprehensive change management strategy to transition facilities to standardized UM workflows, policies, and performance expectationsCreate governance structures that balance enterprise consistency with facility-specific clinical needsBuild consensus among site-based leadership teams to adopt centralized UM processes and shared service modelsEstablish standardized work queues, case assignment methodologies, and productivity expectations across the systemDesign communication strategies to support cultural shifts from site autonomy to enterprise integrationDevelop phased implementation plans that minimize disruption while achieving standardization goalsCreate feedback mechanisms to ensure facility voices are heard throughout the centralization processRegulatory Compliance & Quality Oversight :Ensure enterprise-wide compliance with CMS Conditions of Participation for Utilization Review and Discharge Planning across all 15 hospitalsOversee compliance with Two-Midnight Rule, Observation services guidelines, and all applicable federal and state regulationsLead organizational response to regulatory changes, RAC audits, payer audits, and external reviewsCollaborate with Compliance, Legal, and Quality departments to address utilization management-related risks and findingsMonitor and report on quality metrics related to avoidable days, unnecessary admissions, and readmission preventionDevelop and implement denial prevention strategies based on comprehensive root cause analysis of authorization and medical necessity denialsFinancial & Operational Excellence:Oversee UM operations across the continuum of care with accountability for length of stay optimization, appropriate level of care placement, and denial reductionDrive measurable financial impact through reduced avoidable days, improved observation-to-inpatient conversion appropriateness, and authorization denial preventionMonitor and analyze the financial impact of UM decisions, including write-offs related to missing authorizations and medical necessity denialsDevelop executive-level reporting and dashboards that demonstrate UM program value and ROILead business case development for UM technology investments and staffing optimizationConduct benchmarking analysis against peer academic medical centers and national standardsLeadership & Talent Development:Provide leadership and direction to UM Directors and a workforce across the enterprise, including both employed staff and vendor managementBuild high-performing teams through strategic recruitment, onboarding, competency assessment, and professional development initiativesEstablish standardized training programs for UM staff on medical necessity criteria, payer requirements, and regulatory complianceCreate career pathways and succession planning for UM professionals across the organizationLead organizational change management initiatives related to UM process improvements and technology implementationsFoster a culture of collaboration between UM staff, case management, social work, and clinical teamsClinical & Physician Engagement:Cultivate strong collaborative relationships with Chief Nursing Officers, Chief Medical Officers, Physician Advisors, and department chairs across all facilitiesPartner with clinical leadership to address patterns of inappropriate admissions, delayed discharges, or care setting optimization opportunitiesDesign and deliver education to clinical staff and physicians on medical necessity criteria, Two-Midnight Rule, and documentation requirements for UMServe as the organizational expert on utilization management best practices, regulatory requirements, and payer policiesLead physician advisor integration into UM processes for complex cases and appealsCare Coordination & Transition Management:Oversee integration of UM with discharge planning, case management, and care transitions across the continuumDevelop strategies to reduce length of stay while maintaining quality outcomes and patient satisfactionCollaborate with post-acute care partners to ensure appropriate care transitions and reduce readmissionsLead initiatives to optimize observation services utilization and inpatient admission appropriatenessPartner with Population Health and Value-Based Care teams to align UM strategies with risk-based contractsVendor & Technology Management:Manage strategic relationships with UM vendors, ensuring contractual compliance and optimal performanceOversee EMR work queue optimization and automation opportunities within Epic or other EHR platformsLead evaluation and implementation of AI-powered UM tools and predictive analytics for proactive interventionEnsure seamless integration between UM systems, clinical documentation platforms, and revenue cycle technologiesMonitor vendor performance metrics and lead continuous improvement initiativesAnalytics & Performance Improvement:Establish enterprise-wide UM dashboards and key performance indicators with actionable insights for executive leadershipUtilize data analytics to identify utilization patterns, outlier variation, and opportunities for targeted interventionLead data-driven performance improvement initiatives with measurable outcomes in appropriate resource utilizationTranslate complex utilization data into compelling narratives for diverse stakeholder audiences, including Board presentationsMonitor denial trends and authorization write-offs, implementing corrective action plans as neededMinimum Qualifications:Education:Bachelor’s degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field, required.Master’s degree strongly preferred.Licensure, Certification & Registration:Active RN license preferred.ACM (Accredited Case Manager) or CCM (Certified Case Manager), strongly preferred.Experience:Minimum 8 years of progressive leadership experience in Utilization Management, Case Management, or Revenue Cycle OperationsMinimum 3 years in senior leadership roles with multi-site responsibilityDemonstrated experience managing teams and achieving measurable operational and financial outcomesExperience with UM vendor management and contract oversightExperience leading regulatory compliance initiatives and responding to external auditsPreferred Qualifications & Skills:Experience in an academic medical center or a large integrated delivery networkClinical background in acute care nursing, case management, or utilization reviewExperience with AI or predictive analytics applications in utilization managementPublished research or presentations at national conferences (NAUM, ACMA, CMSA)Teaching or training experience in a healthcare-related disciplineExperience serving on organizational committees (Quality, Patient Safety, Revenue Cycle)Dept./Unit-Specific Skills:Executive presence with the ability to influence and partner with senior clinical and operational leadershipDeep expertise in medical necessity criteria (InterQual, MCG, or similar), CMS regulations, and payer authorization requirementsComprehensive knowledge of CMS Conditions of Participation for Utilization Review and Discharge PlanningStrong understanding of the Two-Midnight Rule, Observation services, and Inpatient Prospective Payment System (IPPS)Strategic thinking with the ability to translate organizational priorities into actionable UM initiativesAdvanced analytical skills with the ability to interpret complex utilization data and identify improvement opportunitiesExperience with Epic EHR and UM workflow technologiesExceptional communication skills with the ability to present to executive and board-level audiencesChange management expertise with demonstrated success leading process improvement initiativesUnderstanding of value-based care models and their impact on utilization management strategiesBudget development and vendor management experienceProven change management expertise with demonstrated success leading organizational transformation and centralization initiativesAbility to build consensus and influence stakeholders across multiple sites with diverse operational culturesExperience navigating complex political dynamics inherent in transitioning from site autonomy to enterprise standardizationStrong diplomatic skills with the ability to balance enterprise efficiency goals with facility-specific needs and concernsPay Range:$180,000.00 USD – $210,000.00 USDThe pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.Equal Opportunity Employer/Veterans/DisabledJob detailsEmployment: Full-timeHours/Week: 40Shift: DayCategory: Revenue CyclePay Range: $180,000.00 USD - $210,000.00 USDFLSA: ExemptReq ID: JR95185