Director, Utilization Management

Overview The Director of Utilization Management (UM) provides enterprise-wide leadership over medical necessity and level-of-care (LOC) processes, including authorization standards, escalation pathways, and payor engagement to support clinical throughput and revenue integrity. This leader is accountable for end-to-end UM execution - admission, concurrent, and retrospective review; exception management; and peer-to-peer (P2P) coordination, grounded in evidence-based criteria and regulatory/accreditation requirements, while driving clinical denial prevention and recovery. The Director partners with Physician Advisors, Care Management (CM), Quality, CDI, and other Revenue Cycle leaders to reduce avoidable denials and length of stay (LOS)-related avoidable days, improve payor outcomes, and drive performance, compliance, and enterprise standardization. Qualifications Education: Bachelor’s degree in Nursing (BSN) required. Master’s degree preferred. Experience: Minimum of 7 to 10 years of progressive healthcare experience, including utilization management experience. Minimum of 3 to 5 years of leadership experience managing teams, programs, or enterprise-level initiatives. License/Certification/Registration:Active Registered Nurse (RN) license required.Preferred certifications include:ACM (Accredited Case Manager)CCM (Certified Case Manager)CMAC (Case Management Administrator Certification)CPHQ (Certified Professional in Healthcare Quality)Other related utilization management, case management, or quality credentials Demonstrated strategic, enterprise-level decision-making ability that balances:Quality of patient careRegulatory complianceFinancial stewardshipOrganizational goals Proven experience in:Team leadership and talent developmentStaff coaching and mentoringBuilding high-performing teams Executive-ready communication skills, including:Written communicationVerbal communicationFacilitation and presentation skillsExecutive stakeholder engagement Strong change leadership capabilities with a continuous improvement mindset. Demonstrated performance management discipline, including:Key Performance Indicators (KPIs)Operational cadenceAccountability frameworks Proven ability to influence and align stakeholders across:Clinical operationsCase managementUtilization managementRevenue cycle operationsExecutive leadership Deep expertise in:Medical necessity determinationsLevel of Care (LOC) criteriaObservation versus inpatient status reviewsTwo-Midnight Rule requirementsUtilization management best practices Extensive experience with:Prior authorization operationsConcurrent review processesUtilization review workflowsDenial prevention strategies Working knowledge of:Diagnosis-Related Groups (DRGs)ICD-10-CM codingICD-10-PCS codingHealthcare reimbursement methodologiesRevenue cycle principles Strong compliance leadership capabilities, including the ability to translate regulatory and accreditation requirements into operational practice, including:CMS Conditions of Participation (CoPs)The Joint Commission standardsAudit readiness requirementsRegulatory compliance expectations Expertise in utilization and throughput analytics, including:Length of Stay (LOS) driversAvoidable days analysisDenial trendsResource utilization reviewPerformance reporting Proficiency with:Utilization management technologiesReporting and analytics toolsOperational dashboardsPerformance monitoring systems Strong payor relationship management skills, including:Escalation managementNegotiation supportResolution of authorization and medical necessity disputes Demonstrated experience collaborating with:Physician AdvisorsPayersCase Management teamsClinical teamsRevenue Cycle stakeholdersOperational leadership Strong analytical, organizational, leadership, and problem-solving skills with a focus on quality outcomes, regulatory compliance, utilization management excellence, and financial performance.