System Manager-Utilization Review

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.