Utilization Review Lead The Bradley Center, Full Time Day

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

• The Utilization Review Lead supports the Director of Care Management by leading the daily operations of the utilization management program. This position facilitates/manages concurrent and retrospective reviews, oversees denial and appeals processes, manages team workflows, supports compliance with payer and regulatory requirements, and serves as a liaison between clinical departments, payers, and medical staff to ensure appropriate utilization of hospital services.

Essential Functions

• Leads and coordinates Utilization Review (UR) staff workflows and coverage schedules to ensure comprehensive hospital-wide utilization management.
• Performs and supervises reviews to assess appropriateness of admission, level of care, continued stay, and discharge planning.
• Acts as a resource for UR staff regarding utilization criteria, payer guidelines, and review documentation.
• Manages clinical denial and appeal processes, including analysis, submission, and tracking of appeals.
• Coordinates with medical staff, discharge planners, and insurance providers to facilitate timely and appropriate care transitions.
• Maintains and evaluates UR policies and procedures to ensure compliance with CMS, state, federal, and Joint Commission standards.
• Serves as liaison with external physician reviewers, Quality Improvement Organizations, and third-party payers.
• Oversees data collection, statistical analysis, and reporting of UR metrics and denial trends.
• Provides onboarding and continuing education for UR staff and serves as the content expert on utilization review processes.
• Participates in hospital committee meetings, care team rounds, and quality improvement initiatives.
• Assists with department budget planning and monitoring of resource utilization.
• Supports collaboration with discharge planning and case management to enhance care coordination.

Knowledge/Skills/Abilities/Expectations

• In-depth knowledge of UR procedures, payer requirements, and clinical guidelines
• Strong understanding of CMS, QIO, and TJC regulations
• Excellent analytical, organizational, and communication skills
• Ability to mentor staff, manage conflict, and lead department operations
• Proficient in data entry, reporting tools, EMR systems, and Microsoft Office
• Primarily sedentary with frequent use of computer and phone
• Occasional walking throughout medical facility; light lifting of files or supplies
• Hospital or office setting with regular interaction with clinical teams and administrative staff
• Exposure to confidential patient and payer information; must comply with HIPAA and privacy standards

Education

• Associates degree or higher in a healthcare related field, business administration, billing/coding

Licenses/Certifications

• Current RN license in applicable state Preferred
• Certification in Case Management (CCM, ACM) or Utilization Review Preferred

Experience

• Minimum 1 year of experience in utilization review, case management or business administration Required
• Prior experience in a leadership, supervisory, or educator role Preferred