Utilization Management Director - Drive Revenue & Care

Northeast Georgia Health System; Gainesville (GA); Remote; USD 140,000 - 200,000; Full time

Job summary

Northeast Georgia Health System in Georgia is seeking a Director of Utilization Management to lead the UM function, optimize reimbursement, reduce denials, and improve CMI. You will collaborate with hospital leadership, physicians, case management, finance, and compliance to drive efficiency and revenue cycle performance.

The role requires RN licensure with UR certification preferred, a Bachelor’s degree, and at least 7 years in UR with 2+ years in revenue cycle leadership.

Qualifications

• RN licensure required; UR certification preferred (CCM/ACM/CPUR)
• 7+ years UR experience with 2+ years revenue cycle leadership
• Bachelor's degree in nursing or related field required
• Master’s degree preferred in nursing or health-related field

Responsibilities

• Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards.
• Collaborate with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance.
• Monitor and analyze KPIs, financial goals, and LOS metrics to drive performance improvements.
• Recruit, train, and manage a high-performing UM team, ensuring alignment with hospital objectives.
• Manage departmental budgets and ensure financial resource allocation.
• Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement.
• Foster relationships with hospital executives, physicians, and payers to support UM initiatives.
• Provide data-driven insights and strategic recommendations to hospital leadership on UM performance.
• Lead process improvement initiatives related to utilization management and revenue cycle optimization.
• Work with Physician Advisors to develop policies on clinical status, medical necessity, denials, and appeals.
• Review daily, weekly and monthly reports to monitor UM performance, identify trends, and keep leadership informed.
• Oversee UM in collaboration with Case Management and interdisciplinary teams for LOS and throughput.
• Communicate UM policies and procedures to physicians and key stakeholders to ensure safe, effective services and transitions of care.
• Assess workload to determine staffing allocations to meet productivity standards.
• Collaborate with physicians and staff to provide clinical/financial data for hospital/physician performance improvements.
• Participate as operational leader for UM in committees such as MRUR; Compliance; Policy and Procedures; and Quality.
• Maintain relationships with Managed Care, Patient Financial Services, and other departments to facilitate utilization review and continuity of care.

Skills

Leadership

Budget management

KPI tracking

Data analysis

Physician engagement

Education

Bachelor's degree

Master’s degree preferred

Job description

Northeast Georgia Health System in Georgia is seeking a Director of Utilization Management to lead the UM function, optimize reimbursement, reduce denials, and improve CMI. You will collaborate with hospital leadership, physicians, case management, finance, and compliance to drive efficiency and revenue cycle performance.

The role requires RN licensure with UR certification preferred, a Bachelor’s degree, and at least 7 years in UR with 2+ years in revenue cycle leadership.