Utilization Review Jobs in Boston, MA (NOW HIRING)

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The Executive Director of Utilization Management (UM) provides strategic and operational leadership for the enterprise UM program across all Beth Israel Lahey Health (BILH) facilities. This role will lead the transformation of UM operations from a decentralized model to an integrated, centralized enterprise function with standardized processes, shared best practices, and consistent performance across all facilities. This executive-level position is responsible for developing and executing comprehensive utilization management strategies that ensure appropriate care delivery in the most clinically and financially optimal settings while maintaining regulatory compliance and optimizing reimbursement. The Executive Director partners with senior clinical and operational leaders, including the Chief Nursing Officers, Chief Medical Officers, Physician Advisors, and payer partners, to align UM initiatives with organizational goals of care coordination, length of stay optimization, and denial prevention while managing UM directors and staff across the system.

Job Description:

Essential Duties & Responsibilities, including but not limited to:

Strategic Leadership & Program Development:

• Develop and execute enterprise-wide UM strategic plans aligned with BILH's clinical, financial, quality, and population health objectives
• Lead the evaluation, selection, and management of UM vendor partnerships and technology solutions, including InterQual, MCG, or other medical necessity criteria platforms
• Design and operationalize standardized UM policies, procedures, and best practices across all BILH facilities, leading the transition from decentralized site-based operations to an integrated enterprise model while ensuring compliance with CMS Conditions of Participation
• Serve as executive sponsor for the Utilization Management Committee and lead the annual review and implementation of the system-wide Utilization Management Plan
• Drive innovation in care coordination models that support value-based care initiatives and alternative payment models
• Establish strategic payer relationships to optimize authorization processes and reduce administrative burden

Enterprise Integration & Standardization:

• Lead the strategic evolution of UM operations from facility-based models to a centralized, standardized enterprise function
• Assess current state UM practices across all 15 hospitals to identify opportunities for standardization, efficiency gains, and best practice adoption
• Develop and implement a comprehensive change management strategy to transition facilities to standardized UM workflows, policies, and performance expectations
• Create governance structures that balance enterprise consistency with facility-specific clinical needs
• Build consensus among site-based leadership teams to adopt centralized UM processes and shared service models
• Establish standardized work queues, case assignment methodologies, and productivity expectations across the system
• Design communication strategies to support cultural shifts from site autonomy to enterprise integration
• Develop phased implementation plans that minimize disruption while achieving standardization goals
• Create feedback mechanisms to ensure facility voices are heard throughout the centralization process

Regulatory Compliance & Quality Oversight :

• Ensure enterprise-wide compliance with CMS Conditions of Participation for Utilization Review and Discharge Planning across all 15 hospitals
• Oversee compliance with Two-Midnight Rule, Observation services guidelines, and all applicable federal and state regulations
• Lead organizational response to regulatory changes, RAC audits, payer audits, and external reviews
• Collaborate with Compliance, Legal, and Quality departments to address utilization management-related risks and findings
• Monitor and report on quality metrics related to avoidable days, unnecessary admissions, and readmission prevention
• Develop and implement denial prevention strategies based on comprehensive root cause analysis of authorization and medical necessity denials

Financial & Operational Excellence:

• Oversee UM operations across the continuum of care with accountability for length of stay optimization, appropriate level of care placement, and denial reduction
• Drive measurable financial impact through reduced avoidable days, improved observation-to-inpatient conversion appropriateness, and authorization denial prevention
• Monitor and analyze the financial impact of UM decisions, including write-offs related to missing authorizations and medical necessity denials
• Develop executive-level reporting and dashboards that demonstrate UM program value and ROI
• Lead business case development for UM technology investments and staffing optimization
• Conduct benchmarking analysis against peer academic medical centers and national standards

Leadership & Talent Development:

• Provide leadership and direction to UM Directors and a workforce across the enterprise, including both employed staff and vendor management
• Build high-performing teams through strategic recruitment, onboarding, competency assessment, and professional development initiatives
• Establish standardized training programs for UM staff on medical necessity criteria, payer requirements, and regulatory compliance
• Create career pathways and succession planning for UM professionals across the organization
• Lead organizational change management initiatives related to UM process improvements and technology implementations
• Foster a culture of collaboration between UM staff, case management, social work, and clinical teams

Clinical & Physician Engagement:

• Cultivate strong collaborative relationships with Chief Nursing Officers, Chief Medical Officers, Physician Advisors, and department chairs across all facilities
• Partner with clinical leadership to address patterns of inappropriate admissions, delayed discharges, or care setting optimization opportunities
• Design and deliver education to clinical staff and physicians on medical necessity criteria, Two-Midnight Rule, and documentation requirements for UM
• Serve as the organizational expert on utilization management best practices, regulatory requirements, and payer policies
• Lead physician advisor integration into UM processes for complex cases and appeals

Care Coordination & Transition Management:

• Oversee integration of UM with discharge planning, case management, and care transitions across the continuum
• Develop strategies to reduce length of stay while maintaining quality outcomes and patient satisfaction
• Collaborate with post-acute care partners to ensure appropriate care transitions and reduce readmissions
• Lead initiatives to optimize observation services utilization and inpatient admission appropriateness
• Partner with Population Health and Value-Based Care teams to align UM strategies with risk-based contracts

Vendor & Technology Management:

• Manage strategic relationships with UM vendors, ensuring contractual compliance and optimal performance
• Oversee EMR work queue optimization and automation opportunities within Epic or other EHR platforms
• Lead evaluation and implementation of AI-powered UM tools and predictive analytics for proactive intervention
• Ensure seamless integration between UM systems, clinical documentation platforms, and revenue cycle technologies
• Monitor vendor performance metrics and lead continuous improvement initiatives

Analytics & Performance Improvement:

• Establish enterprise-wide UM dashboards and key performance indicators with actionable insights for executive leadership
• Utilize data analytics to identify utilization patterns, outlier variation, and opportunities for targeted intervention
• Lead data-driven performance improvement initiatives with measurable outcomes in appropriate resource utilization
• Translate complex utilization data into compelling narratives for diverse stakeholder audiences, including Board presentations
• Monitor denial trends and authorization write-offs, implementing corrective action plans as needed

Minimum Qualifications:

Education:

Bachelor’s degree in Nursing, Healthcare Administration, Health Information Management, or related healthcare field, required.

Master’s degree strongly preferred.

Licensure, Certification & Registration:

Active RN license preferred.

ACM (Accredited Case Manager) or CCM (Certified Case Manager), strongly preferred.

Experience:

• Minimum 8 years of progressive leadership experience in Utilization Management, Case Management, or Revenue Cycle Operations
• Minimum 3 years in senior leadership roles with multi-site responsibility
• Demonstrated experience managing teams and achieving measurable operational and financial outcomes
• Experience with UM vendor management and contract oversight
• Experience leading regulatory compliance initiatives and responding to external audits

Preferred Qualifications & Skills:

• Experience in an academic medical center or a large integrated delivery network
• Clinical background in acute care nursing, case management, or utilization review
• Experience with AI or predictive analytics applications in utilization management
• Published research or presentations at national conferences (NAUM, ACMA, CMSA)
• Teaching or training experience in a healthcare-related discipline
• Experience serving on organizational committees (Quality, Patient Safety, Revenue Cycle)

Dept./Unit-Specific Skills:

• Executive presence with the ability to influence and partner with senior clinical and operational leadership
• Deep expertise in medical necessity criteria (InterQual, MCG, or similar), CMS regulations, and payer authorization requirements
• Comprehensive knowledge of CMS Conditions of Participation for Utilization Review and Discharge Planning
• Strong understanding of the Two-Midnight Rule, Observation services, and Inpatient Prospective Payment System (IPPS)
• Strategic thinking with the ability to translate organizational priorities into actionable UM initiatives
• Advanced analytical skills with the ability to interpret complex utilization data and identify improvement opportunities
• Experience with Epic EHR and UM workflow technologies
• Exceptional communication skills with the ability to present to executive and board-level audiences
• Change management expertise with demonstrated success leading process improvement initiatives
• Understanding of value-based care models and their impact on utilization management strategies
• Budget development and vendor management experience
• Proven change management expertise with demonstrated success leading organizational transformation and centralization initiatives
• Ability to build consensus and influence stakeholders across multiple sites with diverse operational cultures
• Experience navigating complex political dynamics inherent in transitioning from site autonomy to enterprise standardization
• Strong diplomatic skills with the ability to balance enterprise efficiency goals with facility-specific needs and concerns

Pay Range:

$180,000.00 USD - $210,000.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. 

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger. Equal Opportunity Employer/Veterans/Disabled