Manager Acute Care-Utilization Review

Southeast Georgia Health System Inc / SGHS; Brunswick (GA); On-site; USD 90,000 - 130,000; Full time

Job summary

Southeast Georgia Health System Inc / SGHS is seeking a leader to manage the Utilization Review program, ensuring accurate patient status and regulatory compliance. You will supervise UR staff and collaborate with physicians, PSOs, Case Management, Coding, CDI, and Revenue Cycle teams to optimize care levels and reimbursement.

Role requires directing reviews using InterQual/MCG criteria, monitoring payer requirements, reducing denials, and guiding policy development and staff education for

Qualifications

• RN with strong regulatory knowledge and payer policy understanding.
• Experience leading UR teams and collaborating with clinicians.
• Familiar with evidence-based criteria and CMS requirements.

Responsibilities

• Plan, organize, and lead the Utilization Review program and staff.
• Direct concurrent medical necessity reviews using InterQual/MCG criteria.
• Ensure regulatory compliance and optimal reimbursement pathways.
• Monitor denials, educate staff, and partner with Revenue Cycle teams.
• Develop policies, metrics, and budgets for the UR department.

Skills

Leadership

Regulatory compliance

Healthcare payer policy

Team supervision

Education

Registered Nurse (RN)

Tools

InterQual

MCG

CMS Guidelines

Job description

Responsible for the planning, organization, and daily operations of the Utilization Review (UR) program to ensure accurate patient status determination, regulatory compliance, and optimal reimbursement. Provides direct supervision and leadership for the Utilization Review team while collaborating closely with physicians, Patient Status Officers (PSOs), Case Management, Coding, Clinical Documentation Integrity (CDI), and Revenue Cycle teams to ensure patients are assigned the appropriate level of care prior to discharge.

Directs concurrent medical necessity reviews using nationally recognized evidence-based criteria, including InterQual®, MCG®, and applicable commercial payer medical necessity guidelines, to support appropriate inpatient, observation, and outpatient status assignment. Monitors payer-specific authorization requirements and collaborates with commercial and governmental payers to proactively resolve patient status issues, minimize denials, and improve reimbursement outcomes.

Oversees secondary utilization reviews, payer escalations, peer-to-peer review coordination, medical necessity reconsiderations, and concurrent status appeals. Performs complex medical record reviews and provides clinical recommendations to support appropriate status determinations based on documented clinical evidence.

Maintains and updates the CMS-required Utilization Review Plan and ensures compliance with all applicable CMS Conditions of Participation, commercial payer requirements, and federal and state regulatory standards. Develops departmental policies, auditing processes, performance metrics, and staff education to promote regulatory compliance and continuous quality improvement.

Analyzes utilization trends, payer denials, avoidable observation conversions, and length-of-stay opportunities to improve operational performance and reduce post-discharge status denials. Partners with Patient Care Services, Transfer Center, Physician Leaders, Revenue Integrity Patient Financial Services, and Managed Care to support middle revenue cycle initiatives that improve revenue capture, reduce reimbursement risk, and enhance payer relationships.

Develops departmental goals, staffing plans, productivity standards, and annual operating budgets while monitoring financial performance and departmental outcomes. Promotes a collaborative, data-driven environment focused on regulatory compliance, patient status accuracy, operational efficiency, and physician and payer engagement.

Service Excellence: All team members of Southeast Georgia Health System will promote service excellence by developing and maintaining positive relationships with customers, other team members, and the medical staff and will ensure the highest quality of care by performing their responsibilities according to the highest professional standards.

Preferred

Registered Nurse

Equal Opportunity Employer
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