Utilization Management Director - RN Required

Job Category:

Executive Leadership, Revenue Cycle

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Director of Utilization Management (UM) is responsible for leading and managing the Utilization Management (UM) functions at Northeast Georgia Medical Center. This position plays a critical role in ensuring correct status assignment, optimizing reimbursement, minimizing denials, improving case mix index (CMI), and ensuring appropriate utilization of hospital resources. The Director works collaboratively with hospital leadership, physicians, case management, finance, and compliance teams to enhance quality reporting, patient outcomes, and financial integrity. This role serves as a key liaison between clinical and financial operations, ensuring a seamless integration of documentation integrity with utilization management to drive efficiency, compliance, and revenue cycle optimization.

Minimum Job Qualifications

• Licensure or other certifications: Registered Nurse, UR specific certification preferred (CCM, ACM, CPUR)

• Educational Requirements: Bachelors Degree

• Minimum Experience: Minimum of 7 years UR with progressive Revenue Cycle leadership experience of 2 or more years.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Master's Degree in Nursing or other health related field preferred

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Proven ability to lead teams, manage budgets, and implement strategic initiatives.

• Strong ability to educate and influence physicians, staff, and leadership on UM best practices.

• Experience in data analysis, KPI tracking, and performance improvement strategies.

• Expertise in medical necessity criteria, payer regulations, and revenue cycle principles.

Essential Tasks and Responsibilities

• Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards.

• Work closely with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance.

• Monitor and analyze key performance indicators (KPIs), financial goals, and length of stay (LOS) metrics to drive performance improvements.

• Recruit, train, and manage a high-performing UM team, ensuring operational alignment with hospital objectives.

• Manage departmental budgets, ensuring financial responsibility and resource allocation

• Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement.

• Foster strong relationships with internal and external stakeholders, including hospital executives, physicians, and payers.

• Provide data-driven insights and strategic recommendations to hospital leadership regarding UM performance.

• Act as the operational leader for process improvement initiatives related to utilization management, and revenue cycle optimization.

• Work closely with Physician Advisors to develop and revise policies and procedures related to clinical status determination, medical necessity, denials and appeals, and physician education.

• Review daily, weekly and monthly reports to monitor and analyze performance of UM departments, assess data against KPI standards and goals, and identifies trends to make adjustments as indicated. Keeps leadership, staff, and clinical staff (where appropriate) informed.

• Oversees UM working closely with Case Management and other members of the interdisciplinary team to ensure effective collaboration for length of stay and throughput.

• Communicate with and educate physicians and other key stake holders regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care.

• Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently.

• Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/physician performance and anticipating payer and managed care demands.

• Actively participates as the operational leader for UM in committees including but not limited to MRUR; Compliance; Policy and Procedures; and Quality

• Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
  

Physical Demands

• Weight Lifted: Up to 20 lbs, Frequently 31-65% of time

• Weight Carried: Up to 20 lbs, Frequently 31-65% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Constantly 66-100%

• Pushing/Pulling: Constantly 66-100%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.