**Overview** Baylor St. Luke’s Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care neuroscience oncology transplantation and more. Our team’s efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment our new McNair Campus is designed around the human experience—modeled on evidence-based practices for the safety of patients visitors staff and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care research and education. Our strong alliance with Texas Heart® Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve. The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics. **Responsibilities** 1. Manages programs that emphasize appropriate admissions, concurrent and retrospective review of care, and concurrent denials 2. Provides overall direction, design, development, implementation and monitoring of utilization programs to meet the Care Coordination goals and market utilization management goals while maintaining stakeholder satisfaction. 3. Acts as a resource to the medical staff, administrative staff, divisional staff, as well as external regulatory agencies in all issues relating to utilization management within the Market. 4. Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental, Utilization Management, Revenue Cycle, Payer Strategy, and Clinical Joint Operating Committees. 5. Participates in the development and management of department budgets and productivity targets. 6. Assures compliance with Federal, State, The Joint Commission (TJC), Det Norske Veritas (DNV), and other regulatory agencies and internal standards and requirements 7. Collaborates with Physician Advisory Services to identify denial root causes related to physician performance and facilitates educational training for medical staff on issues related to utilization management. 8. Implements utilization review policies and procedures. 9. Directs recruitment, performance management, coaching, mentoring, training and development. Educates and trains staff on utilization review processes and guidelines. 10. Promotes collaborative practice with revenue cycle stakeholders and facilitates data sharing that provides insight into where best to focus concentrated denial prevention and management efforts designed to reduce costly delays in payment and maximize claims reimbursement revenue. 11. Shall be able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding resource allocation needs for future planning purposes. 12. Collaborates with division and system leadership, revenue cycle, and other stakeholders to ensure achievement of denial reduction and value capture goals. **Qualifications** Required Education and Experience: **Required** ● Bachelor's degree in Nursing **(BSN)** , Health Care Administration or advanced clinical degree. ● Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination) ● 5 years of progressively responsible management experience ● Extensive operational experience in managed care; extensive experience in program planning, implementation, staff development, and needs assessment ● Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements. Preferred ● Master's degree in Nursing, Health Care Administration or related clinical field ● Experience with data analytics to include cost containment, over/under utilization assessment and clinical outcomes ● Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services Required Licensure and Certification: ● Current unrestricted RN license where practicing required. ● National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within 2 years upon hire. Required Minimum Knowledge, Skills, Abilities and Training: ● Able to apply clinical guidelines to ensure progression of care. ● Communicate effectively in writing and verbally ● Must have analytical, critical thinking and problem-solving skills. ● Collaborate effectively with multiple stakeholders ● Proficient in the use of computer and multiple software programs. ● Ability to actively work within multiple electronic health records (Epic, Cerner, Meditech, and/or Parigon). ● Understand how utilization management and case management programs integrate. ● Ability to work as a team player and assist other members of the team where needed. ● Thrive in a fast paced, self-directed environment. ● Knowledge of CMS standards and requirements. ● Proficient in prioritizing work and delegating where indicated. ● Highly organized with excellent time management skills. \#LI-CHI **Pay Range** $49.20 - $71.34 /hour We are an equal opportunity/affirmative action employer.