Strategic System Utilization Review Leader

Baptist Memorial Health Care; Memphis (TN); On-site; USD 110,000 - 150,000; Full time

Job summary

Baptist Memorial Health Care is seeking a System Utilization Review Manager to provide system-level leadership over utilization review operations. You will ensure timely, compliant reviews of medical necessity, level of care, and payer authorization while partnering with Case Management, Physician Advisors, Revenue Cycle, Nursing, Quality, and hospital leadership.

Responsibilities include overseeing UR staff, monitoring reviews and authorization workflows, analyzing denial trends, and

Qualifications

• Bachelor’s degree in Nursing and an active RN license are required.
• Minimum five years in utilization review/management.
• Knowledge of medical necessity criteria, payer authorization, CMS guidelines, and regulatory requirements.
• Experience leading utilization review across facilities or markets is preferred.

Responsibilities

• Lead system utilization review processes to ensure compliance with policies and regulatory standards.
• Provide oversight and performance management for UR staff.
• Monitor patient status, level-of-care determinations, and authorization workflows.
• Collaborate with physicians, case management, revenue cycle, and clinical teams to remove barriers to care.
• Analyze utilization data, trends, and denials to identify improvement opportunities.
• Develop and standardize UR workflows, policies, and education.
• Partner with Revenue Cycle, Compliance, and Quality to reduce denials and improve reimbursement.
• Serve as SME for utilization management criteria and payer requirements.
• Support interdisciplinary communication to optimize patient progression and throughput.
• Prepare reports and dashboards for leadership on UR performance.

Skills

Leadership

Communication

Collaboration

Change management

Data analysis

Critical thinking

Attention to detail

Documentation accuracy

Education

Bachelor’s degree in Nursing

Active RN license

Master’s degree (preferred)

Tools

Electronic Health Records

Utilization management platforms

Payer portals

Reporting tools

Job description

Baptist Memorial Health Care is seeking a System Utilization Review Manager to provide system-level leadership over utilization review operations. You will ensure timely, compliant reviews of medical necessity, level of care, and payer authorization while partnering with Case Management, Physician Advisors, Revenue Cycle, Nursing, Quality, and hospital leadership.

Responsibilities include overseeing UR staff, monitoring reviews and authorization workflows, analyzing denial trends, and