Director Remote Utilization Review Jobs in Racine, WI

This is a remote position suporting the Central Area Region requiring up to 75% travel

(Central Area includes NV, AZ, NE, IA, WI, MN, ND)

As our Region Director, Care Coordination, you will provide critical leadership in advancing high-quality, patient-centered care. This includes strategic leadership, operational oversight, clinical direction for patient flow, and ensuring alignment with systemwide standards and regulatory requirements for all hospital Care Management functions across your assigned region.
Every day, as a subject matter expert, you will develop comprehensive plans and drive their implementation to deliver tangible results at the region, market, and hospital levels. Collaborating closely with leadership, you will formulate strategies crucial for meeting organizational objectives. This role ensures consistent implementation of system standards, policies, and best practices for patient-centered care coordination, discharge planning, readmission prevention, and length of stay management. You will align hospital teams to system goals, promote interdisciplinary collaboration, and drive operational excellence in care management performance metrics. Furthermore, you must possess a deep understanding of your supported region to adapt to local regulations, having extensive knowledge of local/regional resources. You will champion relationships with state entities, advocate for resources, and foster relationships with community resources. You will also require knowledge of utilization management processes and denial prevention strategies, actively collaborating with relevant System and Regional Directors to reduce preventable denials and strengthen revenue integrity.
To be successful in your role, you will strategically lead and optimize all hospital Care Management functions across the assigned region, ensuring high-quality, patient-centered care, operational excellence, and strict regulatory compliance. You will demonstrate exceptional executive leadership in developing comprehensive plans, driving implementation, fostering interdisciplinary collaboration, and leveraging your deep understanding of local regulations and resources to achieve critical outcomes in patient throughput, discharge planning, and readmission prevention.

• Strategic Leadership and Operational Excellence: Provides strategic and operational leadership for Care Management functions across all hospitals within the region, ensuring alignment with system priorities and regulatory requirements; Oversees clinical care management operations including progression of care, discharge planning, and social work services, ensuring integration and alignment with system strategies; Leads the implementation and standardization of system policies, procedures, and tools across regional hospitals to promote efficiency, quality, and compliance; Maintains a working knowledge of utilization management workflows, payer requirements, and medical necessity criteria to support accurate level of care determinations and reduce delays; Supports Hospital Directors of Care Management in achieving key performance indicators (LOS, readmissions, discharge efficiency, and patient satisfaction); Monitors and reports regional performance outcomes, identifies variances, and partners with local and system leaders to address opportunities for improvement.
• Collaborative Partnerships and Stakeholder Engagement: Builds and sustains strategic partnerships with system, regional, market, and hospital leaders; Serves as the primary Care Management liaison for the Region Chief Nursing Officer, promoting coordination of care across acute and post-acute settings; Develops strong working relationships with key stakeholders including regional Chief Medical Officers, Chief Financial Officers, Chief Operating Officers, and Post-Acute leadership; Collaborates with the System and Region Director(s) of Utilization Management to ensure cohesive workflows between care management and utilization review; Applies strategies within daily operations to identify trends and address gaps to facilitate authorizations and reduce preventable denials; Facilitates cross-functional collaboration with departments such as Physician Advisory, Revenue Cycle, Payer Strategy, Compliance, Community Health, Behavioral Health, Ethics, Legal, and Quality; Serves as a proactive advisor and subject matter expert, using data analytics and evidence-based practices to inform decision-making and optimize outcomes; Develops relationships with local/state agencies and associations to optimize resources available to patients; Collaborates with post-acute and community partners to ensure seamless patient transitions and strengthen network integrity; Engages in Clinical Joint Operating Committees (JOCs) with payers to address utilization trends, resolve systemic issues, and drive collaboration on medical necessity and post-acute authorization practices; Partners with Payer Strategy and Revenue Cycle to ensure compliance with payer requirements and maximize reimbursement opportunities under federal, state, and commercial programs; Represents the region on system-level councils and committees where needed, aligning local initiatives with national goals.
• Strategy Development, Implementation, and Performance Improvement: As a subject matter expert, leads regional execution of system-wide initiatives, such as the various Care Management Playbooks, Shared Governance, and Discharge Optimization programs; Guides hospitals in operationalizing programs that improve progression of care, enhance patient transitions, support throughput, reduce readmissions, reduce avoidable delays, and optimize reimbursement outcomes; Drives operational efficiency and quality through process redesign, standardization, and continuous improvement initiatives;Leverages analytics to inform planning and drive measurable improvements in throughput, patient outcomes, and financial stewardship.
• Workforce Development, Education, and Talent Management: Champions workforce development by ensuring comprehensive orientation, competency, and continuing education for all regional care management staff. Partners with Human Resources and facility leadership to ensure appropriate staffing models, skill mix, and role optimization to meet patient care needs; Identifies and mentors emerging leaders, developing strong succession pipelines and fostering career growth opportunities; Promotes a culture of accountability, engagement, and recognition, ensuring staff are empowered to deliver compassionate, high-quality care management services.
• Regulatory Compliance, Ethics, and Organizational Stewardship: Ensures compliance with all applicable federal, state, and local regulations, as well as accreditation and organizational standards governing care management and social work; Maintains audit readiness and serves as a key liaison during internal and external regulatory reviews; Upholds CommonSpirit Health’s Mission, Vision, and Values, ensuring ethical decision-making and adherence to the Code of Conduct; Champions diversity, equity, inclusion, and belonging within the regional care management structure.
• Additional Responsibilities: Leads or participates in system-wide projects and task forces as assigned; Demonstrates flexibility and resilience in adapting to evolving healthcare environments and organizational priorities.

Required Education and Experience

• Bachelors of Nursing
• Masters or equivalent education
• Minimum of 10 years in acute care management including 5 years in a leadership role overseeing multiple facilities or a regional structure
• Proven success in developing and implementing large-scale care management strategies.
• Registered Nurse license, RN 
• Accredited Case Manager, ACM

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

Required Education and Experience

• Bachelors of Nursing
• Masters or equivalent education
• Minimum of 10 years in acute care management including 5 years in a leadership role overseeing multiple facilities or a regional structure
• Proven success in developing and implementing large-scale care management strategies.
• Registered Nurse license, RN 
• Accredited Case Manager, ACM