What are the responsibilities and job description for the Director of Utilization Management position at CareWell Health Medical Center?
The Director of Utilization Management will oversee all utilization-related functions, ensuring clinical care, regulatory requirements, and payer expectations are aligned while optimizing throughput and revenue integrity.
Reporting Structure
Leadership & Strategy
Minimum Education/Certifications
Reporting Structure
- Reports to: Executive Leadership (VP of Revenue Cycle or Interim Executive in that role)
- Works closely with: CMO, CHRO, Medical Staff leadership, Nursing leadership, Compliance, and Quality
Leadership & Strategy
- Establish and lead the Department of Utilization Management
- Develop standardized policies, workflows, and escalation pathways
- Align department objectives with hospital strategic goals
- Direct oversight of Case Management, UR, CDI, Denials, and P2P functions
- Ensure timely authorizations, reviews, and appeals
- Optimize staffing models and coverage
- Partner with physicians on medical necessity and documentation standards
- Oversee peer-to-peer preparation and escalation
- Support Medical Staff education related to utilization and payer expectations
- Reduce avoidable denials and excess length of stay
- Ensure compliance with CMS, Joint Commission, and payer requirements
- Monitor utilization, quality, and financial performance metrics
- Develop dashboards and routine reporting for executive leadership
- Identify trends, risks, and opportunities for improvement
- Lead continuous performance improvement initiatives
Minimum Education/Certifications
- RN, MD, DO, or other clinically licensed professional (required)
- Bachelor’s degree required; Master’s degree preferred (MBA, MHA, MSN)
- 5–10 years of progressive experience in utilization management, case management, or revenue integrity
- Strong working knowledge of CMS regulations, payer criteria, and denial management
- Demonstrated leadership and change-management experience