System Director: Utilization Review & Denials Strategy

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

Job summary

Baylor Scott & White Health is seeking a Director of Utilization Review to provide strategic leadership and oversight of UR across the system. The role ensures medical necessity is properly validated, and it focuses on concurrent and retrospective denial prevention, regulatory compliance, and performance optimization.

You will partner with clinical and revenue cycle leaders to reduce payer denials, improve appeals, and enhance financial and regulatory outcomes, while guiding a largely remote UR

Qualifications

• Masters degree in nursing or related field and RN license required.
• Minimum 5 years of nursing or utilization review experience.
• At least 1 year in a leadership role.

Responsibilities

• Directs daily UR operations and implements UR policies.
• Develops metrics and executive reports for leadership.
• Partners with Physician Advisors to improve outcomes and utilization.
• Streamlines workflows, reduces redundancies, and improves processes.
• Oversees external vendors and remote/global staff.
• Ensures CMS, Joint Commission and payer regulatory compliance.

Skills

Leadership

Stakeholder management

Strategic planning

Communication

Process improvement

Education

Masters Degree

RN license

Tools

Epic

XSOLIS

InterQual

Job description

Baylor Scott & White Health is seeking a Director of Utilization Review to provide strategic leadership and oversight of UR across the system. The role ensures medical necessity is properly validated, and it focuses on concurrent and retrospective denial prevention, regulatory compliance, and performance optimization.

You will partner with clinical and revenue cycle leaders to reduce payer denials, improve appeals, and enhance financial and regulatory outcomes, while guiding a largely remote UR