Utilization Review Rn Jobs in Raleigh, NC (NOW HIRING)

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Summary:
The Executive System Director of Utilization Management (UM) is a strategic and operational leader responsible for designing, implementing, and standardizing utilization management functions across a large healthcare system, including a complex academic health system and multiple community-based hospitals and care settings. This role provides enterprise-wide oversight to ensure clinically appropriate level of care, regulatory compliance, and effective and efficient management of healthcare resources in alignment with institutional goals.
The Executive Director works closely with leaders from various departments-case management, physician advisors, revenue cycle, medical staff, nursing, and information systems (ISD) to create a unified and standardized utilization management (UM) infrastructure. This collaboration ensures the delivery of high-quality, value-based care across the healthcare system. This role requires deep provider-side utilization management leadership experience within an acute care hospital system, integrated delivery network, or academic healthcare system.
Responsibilities:
1. Utilization Management - Develop and lead a system-wide utilization management strategy to ensure consistent application of UM principles across all entities. Establish and enforce enterprise-wide UM policies, procedures, and performance standards. Lead integration efforts across hospitals with varying operational models, including community hospitals and academic institutions. Ensure uniform application of care level determinations, medical necessity assessments, and documentation enhancement initiatives. Oversees development and utilization of a standardized performance dashboard for utilization management that includes key statistics that impact the success of the organization and the UM program.
2. Leading People - Operational oversight of centralized UM teams, including utilization review nurses and support staff. Cultivate and empower high-performing system-level UM leaders and staff through strategic recruitment, mentorship, and professional development. Nurture a culture of ongoing enhancement, accountability, and excellence within utilization management. Provide an inclusive workplace that fosters the development of others, facilitates cooperation and teamwork, and supports constructive resolution of conflicts. Ensures that team treats sensitive or confidential information appropriately. Works to improve and reinforce performance of others. Ensures adequate staffing and orientation and training of staff. Foster collaboration with medical staff, department chairs, hospital leadership, and finance teams to harmonize utilization management practices, ensuring alignment with clinical and financial objectives. Guide physician engagement initiatives by developing training programs for physician advisors and advocating for evidence-based resource utilization.
3. Leading Change - Drive the unification of diverse operational models across multiple hospital and care settings. Initiates and manages the change process, taking steps to remove barriers or accelerate its pace. Communicates a compelling vision and need for change that generates excitement, enthusiasm, and commitment to the process. Clearly communicates the direction, required performance, and challenges of change to all involved parties. Identifies and enlists the support of key individuals and groups to move the change forward. Obtains and provides resources to implement change initiatives. Serves as a role model by demonstrating commitment to innovation and continuous improvement in organizational performance. Designs, executes, monitors and evaluates recommendations for improvement. Works with entity leaders to develop standardization across the system. Collaborates with key leaders in the organization to optimize key clinical and financial outcomes within best practice, ethical, legal, and regulatory parameters.
4. Results Driven - Implement and optimize technology platforms (e.g. MCG, EMR integrations) for efficient case review and documentation. Establish key performance indicators to monitor compliance with healthcare regulations, measure the effectiveness of the UM program including level of care pre-claim and post claim denial rates, readmission, and analyze and track payer methods to deny or reduce payment. Pinpoint savings opportunities and deploy strategies to enhance resource efficiency. Manage budget and financial performance for utilization management. Understands the overall financial performance of the organization and applies financial concepts and practices.
Other Information
Other information:
Education Requirements:
• Bachelor of Science in Nursing (BSN) and a Master's degree in Nursing, Health Administration, Business Administration, or a related field.
Licensure/Certification Requirements:
• None required.
Professional Experience Requirements:
• Requires a minimum of ten (10) years of progressive provide-side utilization management experience within an integrated health system, with at least seven (7) years of management experience.
Knowledge/Skills/and Abilities Requirements:
• Knowledge and experience with electronic medical record (EMR) and utilization review technology, hospital coding/billing, payer contracting, and Revenue Cycle management. Advanced skills in data analysis and reporting and strategic planning. Experience in clinical system integration and a strong understanding of clinical and care management processes. Demonstrated leadership capabilities and ability to influence others. Advanced critical thinking and judgment skills. Excellent communication and interpersonal skills. Skill in collaborating with multiple departments. Robust understanding of current Medicare and Joint Commission compliance requirements. Successful team facilitation and change management experience. Proven leadership in successfully implementing new strategies. Effective collaboration with physicians, nursing, and ancillary leaders.
Job Details
Legal Employer: NCHEALTH
Entity: Shared Services
Organization Unit: System Care Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Pay offers are determined by experience and internal equity
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: US:NC:Morrisville
Exempt From Overtime: Exempt: Yes
This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job.
Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.