Strategic Utilization Review Leader

Baptist; Memphis (TN); On-site; USD 90,000 - 130,000; Full time

Job summary

Baptist seeks an experienced System Utilization Review Manager to lead system-wide utilization review operations, ensuring timely, accurate, and compliant patient status reviews, medical necessity determinations, and payer authorization across the organization.

You will partner with Case Management, Physician Advisors, Revenue Cycle, Nursing, Quality, Compliance, and hospital leadership to drive performance, reduce denials, improve throughput, and promote cost-effective care through standardized

Qualifications

• Bachelor’s degree in Nursing
• Active Registered Nurse license
• Minimum of five years of progressive experience in utilization review and utilization management
• Strong knowledge of medical necessity criteria, payer authorization processes, patient status determinations, CMS guidance, and regulatory requirements

Responsibilities

• Lead utilization review processes to ensure compliance with policies, payer requirements, CMS regulations, and standards.
• Provide oversight and performance management for utilization review staff across facilities.
• Monitor patient status, reviews, level-of-care determinations, and authorization workflows for timeliness and accuracy.
• Collaborate with Physician Advisors and clinical teams to resolve barriers and support appropriate patient placement.
• Analyze utilization data and trends to identify opportunities for improvement.
• Develop and standardize utilization review workflows and education across the health system.
• Partner with Revenue Cycle, Compliance, and Quality to reduce denials and support accurate reimbursement.
• Serve as SME for utilization management criteria and regulatory guidance.

Skills

Leadership

Communication

Collaboration

Change management

Data-driven decision making

Attention to detail

Regulatory compliance

Problem solving

Prioritization

Clinical documentation review

Education

Bachelor’s degree in Nursing

Active RN license

Job description

Baptist seeks an experienced System Utilization Review Manager to lead system-wide utilization review operations, ensuring timely, accurate, and compliant patient status reviews, medical necessity determinations, and payer authorization across the organization.

You will partner with Case Management, Physician Advisors, Revenue Cycle, Nursing, Quality, Compliance, and hospital leadership to drive performance, reduce denials, improve throughput, and promote cost-effective care through standardized