Revenue Cycle Managed Services - Utilization Management (UM) / Utilization Revie

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Position Summary

The Utilization Review (UR) / Utilization Management (UM) Lead is responsible for day-to-day leadership of the utilization management program for an assigned healthcare client. The role oversees concurrent review, continued-stay review, admission and level-of-care status, retrospective review, and related appeals, and ensures reviews are timely, criteria-based, and aligned with payer and regulatory requirements.

Working with client clinical, case management, revenue cycle, and physician leadership, the UM Lead improves review productivity and turnaround times, reduces authorization and medical-necessity denials, and supports length-of-stay and throughput goals. The role combines operational management, performance monitoring, and practical process improvement.

Key Responsibilities

Operational Leadership

• Lead operational assessments of utilization management, case management, patient throughput, and care coordination functions.
• Evaluate current-state workflows, organizational structures, staffing models, and performance metrics.
• Design and implement scalable operational improvements that increase efficiency and improve service delivery.
• Implement operational improvements that increase review efficiency, consistency, and service delivery.
• Partner with client operational leaders and teams to prioritize UM initiatives that improve performance.

Utilization Management Operations

• Direct daily UM operations, including work distribution, review prioritization, escalation, and coverage.
• Promote consistent application of medical-necessity criteria and appropriate level-of-care status.
• Manage physician-advisor referral and secondary-review processes for cases that do not meet criteria.
• Oversee optimization of prior authorization, concurrent review, retrospective review, and appeals workflows.
• Analyze utilization patterns and operational performance to identify opportunities for improvement.
• Improve turnaround times, productivity, and service-level agreement performance.
• Support implementation of utilization management technologies, automation tools, and workflow enhancements.
• Establish operational standards and key performance indicators for ongoing monitoring and accountability.

Revenue Cycle & Denials Prevention

• Collaborate with revenue cycle, patient access, and clinical operations leaders to reduce authorization-related denials.
• Improve alignment between utilization management, clinical documentation, case management, and revenue cycle functions.
• Develop operational strategies that support reimbursement optimization and financial performance.
• Analyze denial trends and implement corrective action plans to reduce preventable revenue leakage.
• Support initiatives focused on medical necessity documentation and payer compliance.

Throughput & Capacity Management

• Partner with case management and patient-flow leaders on length of stay, discharge barriers, and avoidable days tied to utilization decisions.
• Identify UM-related barriers to care progression and status determination.
• Establish dashboards and reporting tools to monitor throughput performance and operational outcomes.

Process Improvement & Transformation

• Lead targeted operational improvement initiatives within the client UM program.
• Utilize Lean, Six Sigma, or other performance improvement methodologies to redesign workflows.
• Facilitate stakeholder engagement sessions, process mapping workshops, and change management activities.
• Implement performance management frameworks focused on measurable outcomes and continuous improvement.

Data Analytics & Performance Management

• Analyze operational, financial, and utilization data to identify trends and improvement opportunities.
• Develop executive-level dashboards, scorecards, and performance reports.
• Monitor productivity, turnaround times, denial rates, length of stay, and resource utilization metrics.
• Present findings and recommendations to client operational leaders.
• Translate complex data into actionable operational strategies.

Team Leadership

• Provide functional leadership to UM team.
• Coach staff on criteria use, documentation, escalation, and productivity expectations.
• Contribute to playbooks, training, and standard work for the UM program.
• Support business development efforts, including proposal development and client presentations.

Required Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Business Administration, Public Health, or a related field.
• 7+ years of experience in healthcare operations, utilization management, care management, revenue cycle, or performance improvement.
• 3+ years of leadership experience managing operational teams, transformation initiatives, or consulting engagements.
• Strong understanding of utilization management operations, patient throughput, care coordination, and healthcare reimbursement.
• Experience leading operational improvement initiatives within provider, payer, or consulting environments.
• Strong analytical, project management, and stakeholder engagement skills; able to manage competing priorities.

Preferred Qualifications

• Master's degree in Healthcare Administration (MHA), Business Administration (MBA), Public Health (MPH), Nursing, or a related field.
• Consulting experience supporting hospitals, health systems, physician groups, or health plans.
• Experience with denials management, revenue cycle optimization, and patient flow improvement initiatives.
• Familiarity with InterQual®, MCG, Epic, Cerner, or other utilization management and care management platforms.
• Registered Nurse (RN) license preferred but not required.

For salaried positions, this role may also be eligible for an annual performance bonus. Additional benefits and perks may also be available, depending on the position and employment terms. This range reflects consideration of several factors, including skills, experience, training, certifications, and organizational needs.

Our People and Culture

At Impact Advisors, we cultivate a caring, fun, honest, and autonomous work environment. Our success stems from our associates' dedication and a shared mission to create a “Positive Impact.” We embrace diversity and inclusion, fostering an environment where all employees feel valued and empowered.

Join Impact Advisors and make a real difference in healthcare.

Originally posted on Himalayas