System Director, Utilization Review & Denials Management

Baylor Scott & White Health; Denver (CO); On-site; USD 150,000 - 210,000; Full time

Job summary

Baylor Scott & White Health is seeking a Director of Utilization Review to lead strategic and operational UR efforts across the system. The role focuses on ensuring medical necessity, reducing payer denials, and optimizing the appeals process through collaboration with clinical and revenue cycle leaders.

The director will develop and implement policies, monitor performance, and drive system-wide improvements, including workflow simplification and vendor management.

Qualifications

• Masters degree required.
• RN license required.
• 5+ years of nursing/utilization review experience.
• 1+ year of leadership experience.
• Registered Nurse (RN) license.
• Knowledge of InterQual or equivalent criteria.
• Experience with Epic and XSOLIS preferred.

Responsibilities

• Lead strategic and operational plans for utilization management aligned to BSWH objectives.
• Direct daily operations of UR functions and establish UR policies and processes.
• Develop metrics, trends, and executive reporting for senior leadership.
• Collaborate with Physician Advisors and regional leadership to improve outcomes and utilization.
• Streamline UR workflows, reduce redundancies, and improve employee experience.
• Partner with revenue cycle leaders to reduce payer denials and optimize appeals.
• Oversee external vendors and remote/global resources supporting UR.
• Ensure CMS, Joint Commission and payer compliance and regular regulatory reviews.

Skills

RN license

Leadership

Communication

Problem-solving

Process improvement

Cross-functional collaboration

Presentation skills

Education

Masters Degree

Tools

Epic

XSOLIS

InterQual

Job description

Baylor Scott & White Health is seeking a Director of Utilization Review to lead strategic and operational UR efforts across the system. The role focuses on ensuring medical necessity, reducing payer denials, and optimizing the appeals process through collaboration with clinical and revenue cycle leaders.

The director will develop and implement policies, monitor performance, and drive system-wide improvements, including workflow simplification and vendor management.