Director Utilization Management

About the role

The Utilization Management (UM) Director is responsible for market development, implementation, evaluation, and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The role oversees the UM department’s processing of authorizations, inpatient admission and continued‑stay reviews, retrospective authorizations, concurrent denials, appeals, and reconsiderations, while ensuring compliance with payer and regulatory requirements.

Responsibilities

• Develop, implement, evaluate, and direct the Utilization Management Program and its staff.
• Process authorizations, inpatient admission and continued‑stay reviews, and retrospective authorizations using standardized criteria to determine medical necessity.
• Review and process concurrent denials that require medical necessity determinations.
• Handle appeals and reconsiderations.
• Collaborate with the Division Director, Care Coordination, to develop strategies that achieve departmental and CommonSpirit Health goals.
• Direct UM staff to meet or exceed operational performance standards.
• Oversee development and implementation of UM policies, procedures, and processes.
• Direct and assist with accreditation activities.
• Efficiently manage payer requirements, address denials effectively, and ensure compliance with payer and regulatory requirements.
• Review and analyze UM program outcomes and quality metrics.

Requirements

• Bachelor’s degree in Nursing, Health Care Administration, or an advanced clinical degree.
• Minimum 3 years of clinical case management experience (Utilization Management, Denial Management, Care Coordination).
• At least 5 years of progressively responsible management experience.
• Extensive operational experience in managed care, including program planning, implementation, staff development, and needs assessment.
• Comprehensive knowledge of utilization management and financial management, including revenue cycle, Medicare, Medicaid, and commercial admission and review requirements.

Where You’ll Work

Baylor St. Luke’s Medical Center is an 881‑bed quaternary‑care academic medical center, a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital houses the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Dr. Denton A. Cooley. It was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also operates three community emergency centers offering adult and pediatric care for the Greater Houston area.

Pay Range

$52.15 – $77.58 per hour