Director, Utilization Review

Job Summary

Reporting to the Senior Vice President of Revenue Cycle, the Director of Utilization Review is responsible for the strategic leadership, planning, and oversight of utilization review (UR) functions across Baylor Scott & White Health (BSWH). This role ensures effective assessment, validation, and documentation of medical necessity for patient care services, including concurrent and retrospective denial prevention and management, regulatory compliance, and performance optimization. The Director partners closely with clinical, operational, and revenue cycle leadership to drive system-wide performance improvement initiatives, reduce payer denials, optimize the appeal process, and strengthen financial and regulatory outcomes. 

A system Director translates and implements strategic plans and objectives for area of responsibility. Makes final decisions on operational matters and ensures achievement of objectives. Recommends policies and organizational changes for area. Plans and executes projects and initiatives that meet annual objectives. Erroneous decisions at this level tend to have negative impact on the success of the area, business unit, and possibly the overall organization's operations. Plans and directs the operations of a department or area, with responsibility for staffing, processes, budgets, and costs of the unit. Leads and advises subordinate(s) to meet schedules, resolve technical problems, and monitor performance. Has a larger, more complex organization or functional area than a manager. Often has one or more regional directors, managers or supervisors reporting to the role.

Essential Functions of the Role

• Recommends and implements strategic and operational plans and priorities for utilization management aligned to BSWH overall business objectives.
• Directs daily operations of utilization review functions, including the development and implementation of utilization review policies, procedures, and processes.
• Develops and establishes metrics, trends, and executive-level reporting for senior leadership, hospital senior leadership, and senior medical staff. Holds team accountable to achieving best practice performance targets. 
• Partners closely with Physician Advisors and regional leadership to identify opportunities to enhance operational effectiveness, patient outcomes, and resource utilization through the development and implementation of strategic projects and process improvements
• Proactively looks for opportunities to streamline workflows, reduce redundancies, and simplify processes to drive improved outcomes and employee experience
• Partners with revenue cycle leaders/teams to reduce payer denials, track avoidable days and streamline the appeals process for optimal outcomes. 
• Serves as a resource to senior leadership, hospital senior leaders, and medical staff for functions related to utilization review.
• Selects and leads outside vendor and contracted services supporting the utilization review areas. Oversees a workforce that is primarily comprised of remote BSWH employees but also includes global resources in the Philippines. 
• Ensures compliance with CMS, Joint Commission (TJC), and payer requirements. Ensures annual review and regulatory compliance of utilization management plans.

Preferred Qualifications

• Bachelor's degree in nursing or related field
• 5+ years of experience in nursing, utilization review or related area.
• 1+ years of experience in a leadership role.
• Registered Nurse (RN) license.
• Strong working knowledge of Epic required. Experience with XSOLIS preferred.
• Ability to build strong working relationships with internal UR team members and senior leaders across the organization that contribute to a high performance culture
• Knowledge of InterQual or equivalent evidence-based criteria for hospital admission
• Experience collaborating across multiple departments and clinical disciplines within a large, complex healthcare organization 
• Strong problem-solving and critical thinking skills. Excellent verbal, written, and presentation skills. Ability to organize and prioritize high-volume workload. 
• Innovative approach to streamlining UR processes (including pre-certification, concurrent review, appeals and denials, and payer processes) through Epic optimization, AI tools, and process improvement. 

Minimum Qualifications

• EDUCATION - Masters Degree
• EXPERIENCE - (5) Five Years of Experience
• CERTIFICATION/LICENSE/REGISTRATION - Registered Nurse (RN)
• Specialty Certification (SPEC)