System Manager-Utilization Review

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

Overview

System Utilization Review Manager

Job Summary:

The System Utilization Review Manager provides system-level leadership and oversight for utilization review operations across the organization. This role is responsible for ensuring timely, accurate, and compliant review of patient status, medical necessity, level of care, payer authorization, and utilization management processes. The manager partners closely with Case Management, Physician Advisors, Revenue Cycle, Nursing, Quality, Compliance, and hospital leadership to support appropriate resource utilization, reduce avoidable denials, improve patient throughput, and promote high-quality, cost-effective care.

Key Responsibilities

• Lead and manage system utilization review processes to ensure compliance with organizational policies, payer requirements, CMS Conditions of Participation, and applicable regulatory standards.
• Provide operational oversight, coaching, and performance management for utilization review staff across assigned facilities or service areas.
• Monitor patient status, medical necessity reviews, level-of-care determinations, authorization workflows, and concurrent review activities to ensure timely and accurate outcomes.
• Collaborate with Physician Advisors, attending providers, Case Management leaders, and clinical teams to resolve utilization barriers and support appropriate patient placement.
• Analyze utilization data, denial trends, avoidable days, length of stay, observation utilization, and authorization performance to identify opportunities for improvement.
• Develop, implement, and standardize utilization review workflows, policies, education, and best practices across the health system.
• Partner with Revenue Cycle, Managed Care, Compliance, and Quality teams to reduce avoidable denials and support accurate reimbursement.
• Serve as a subject matter expert for utilization management criteria, payer authorization requirements, regulatory guidance, and documentation standards.
• Support interdisciplinary communication and escalation processes to improve patient progression, discharge readiness, and throughput.
• Prepare reports, dashboards, presentations, and recommendations for leadership related to utilization review performance and improvement initiatives.
• Minimum 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.
• Demonstrated ability to analyze data, identify trends, develop action plans, and drive measurable performance improvement.
• Preferred Qualifications
• Master’s degree in Nursing, Healthcare Administration, Business Administration, or a related field.
• Certification in Case Management, Utilization Management, Healthcare Quality, or Revenue Cycle, such as CCM, ACM, CPHQ, or equivalent.
• Experience leading utilization review operations across multiple hospitals, markets, or service lines.
• Experience with electronic health records, utilization management platforms, payer portals, and reporting tools.
• Knowledge of Medicare, Medicaid, commercial payer, managed care, and value-based care requirements.
• Required Skills and Competencies
• Strong leadership, communication, collaboration, and change-management skills.
• Ability to influence physicians, clinical teams, and operational leaders through data, education, and relationship-building.
• Excellent critical thinking, problem-solving, and prioritization abilities in a fast-paced healthcare environment.
• High attention to detail with a strong commitment to compliance, documentation accuracy, and process reliability.
• Proficiency in reviewing clinical documentation and applying evidence-based criteria to support level-of-care decisions.
• Ability to lead standardization efforts while adapting workflows to meet facility-specific operational needs.