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The Director, System Utilization Management (UM) provides strategic and operational leadership for utilization review, and resource management functions across the health system. This role ensures appropriate use of healthcare services, regulatory compliance, and optimal reimbursement, across all facilities and service lines. The Director oversees day-to-day utilization review operations, establishes standardized processes and best practices, and drives organizational alignment to promote cost-effective care. Working collaboratively with clinical, operational, and revenue cycle leadership, this position advances performance improvement initiatives, reduces denials, and strengthens financial and regulatory outcomes across the system.

GENERAL DUTIES:

1. Strategic Leadership

• In conjunction with the Corp VP, Case Management & Utilization, develop and implement a system-wide utilization management strategy aligned with organizational goals.
• Lead standardization of UM processes across hospitals.
• Collaborate with executive leadership and Case Management to reduce denials, prevent avoidable days, and optimize length of stay (LOS).
• Identify trends and implement performance improvement initiatives to enhance clinical and financial outcomes.
• Develop a culture of high performance and continuous improvement that values learning and a commitment to quality, including conducting routine, ongoing audits to ensure with UM established policies and procedures.

2. Regulatory & Compliance Oversight

• Ensure compliance with federal, state, and payer regulations along with all relevant accreditation and regulatory requirements.
• Oversee adherence to InterQual or MCG criteria for medical necessity determinations.
• Ensure compliance with third party payor requirements, both governmental and commercial payors.

3. Revenue Cycle Integration

• Partner with Revenue Cycle, Finance, and Managed Care teams to reduce payer denials and improve reimbursement.
• Monitor denial trends and lead root cause analysis and corrective action plans.
• Oversee appeals processes and ensure timely documentation to support medical necessity.
• Collaborate with the Physician Advisor Team to both reduce denials and identify areas for clinical documentation improvement; collaborate with the Clinical Documentation Integrity Team ("CDI") on documentation improvement initiatives.

4. Clinical Operations Oversight

• Direct inpatient and outpatient utilization review activities.
• Ensure effective communication between physicians, nursing, and payers.

5. Data Analytics & Performance Improvement

• Analyze system-level data including but not limited to LOS, readmissions, avoidable days, denial rates, and throughput.
• Develop dashboards and KPIs to track performance.
• Lead multidisciplinary committees focused on utilization and throughput optimization.

6. Team Leadership & Development

• Provide direct oversight to UM manager and clinical review staff.
• Establish productivity benchmarks and quality standards.
• Mentor leaders and promote professional development.

EDUCATION QUALIFICATIONS:

• Bachelor's degree in nursing, required (master's preferred).

EXPERIENCE QUALIFICATIONS:

• 7-10+ years of progressive leadership experience in Utilization Management or Case Management.
• Experience in multi-hospital or system-level leadership preferred.
• Strong knowledge of payer requirements, CMS regulations, and accreditation standards.
• In depth working knowledge and experience of the EPIC Electronic Health Record System Utilization Management workflows, WQs and data reporting capabilities.

LICENSES AND CERTIFICATIONS:

• Active RN license (if clinical background).
• Certification in Case Management and/or Utilization Management preferred.

WORK SHIFT:

LCMC Health is a community.

Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little "come on in" attitude is the foundation of LCMC Health's culture of everyday extraordinary

Your extras

• Deliver healthcare with heart.
• Give people a reason to smile.
• Put a little love in your work.
• Be honest and real, but with compassion.
• Bring some lagniappe into everything you do.
• Forget one-size-fits-all, think one-of-a-kind care.
• See opportunities, not problems - it's all about perspective.
• Cheerlead ideas, differences, and each other.
• Love what makes you, you - because we do

You are welcome here.

LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law.

The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.

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