System Director, Utilization Review & Denial Management

Baylor Scott & White Health; Denver (CO); On-site; USD 180,000 - 240,000; Full time

Job summary

Baylor Scott & White Health seeks a Director of Utilization Review to lead UR strategy, oversight, and performance across the system. You will ensure medical necessity validation, and align with clinical, operational, and revenue cycle leadership to reduce denials and optimize appeals.

The role drives policy implementation, monitors KPIs, and manages a diverse team including remote staff and global vendors, with emphasis on CMS and payer requirements.

Qualifications

• Masters degree required for leadership role in health system settings.
• RN license required for nursing practice.
• Strong problem-solving and critical thinking skills.
• Excellent verbal and written communication; presentation skills essential.
• Experience with Epic software and utilization review tools preferred.
• Ability to build relationships with senior leaders and clinicians.

Responsibilities

• Directs daily operations of utilization review functions and policies.
• Develops metrics, trends, and executive reporting for leaders and medical staff.
• Leads strategic plans for utilization management aligned to BSWH objectives.
• Partners with Physician Advisors and regional leadership to improve outcomes and efficiency.
• Streamlines UR processes through Epic optimization and process improvements.
• Oversees remote and on-site UR workforce and vendor contracts.

Skills

Leadership experience

Communication skills

Problem-solving

Presentation skills

Collaboration with clinicians

Education

Masters Degree

RN license

Tools

Epic

XSOLIS

Job description

Baylor Scott & White Health seeks a Director of Utilization Review to lead UR strategy, oversight, and performance across the system. You will ensure medical necessity validation, and align with clinical, operational, and revenue cycle leadership to reduce denials and optimize appeals.

The role drives policy implementation, monitors KPIs, and manages a diverse team including remote staff and global vendors, with emphasis on CMS and payer requirements.