RN System Director Utilization Management - Relocation Offered!
- Full-time
General Summary of Position
MedStar Health is looking for a System Director of Utilization
With 10 nationally respected hospitals and over 500 specialty, urgent care, and primary care locations. MedStar Health is the leading healthcare provider in Maryland, DC, and Virginia.
The System Director of utilization is responsible for overseeing utilization review operations across a defined group of hospitals within designated region of Maryland or the District of Columbia. Possesses deep knowledge and expertise specific to regulatory requirements of the region. Responsible for operationalizing strategic vision in partnership with system ACM leaders. Ensures consistent application of evidence-based review practices with oversight and performance management of UR RN teams. Drives performance aligned with regulatory and payor expectations, ensuring the delivery of high-quality care, operational efficiencies, reduction in avoidable utilization, and collaboration with clinical and operational stakeholders.
Requirements :
- MSN Required
- Active DC or MD RN license Required
- 5-7 years' experience in Utilization Management with 3-5 years' experience in Utilization Management Leadership Required
- 3-5 years' experience in acute care bedside nursing Required
Primary Duties and Responsibilities
Directs and develops Utilization Review RN teams and their managers across service lines and region, ensuring operational efficiency and effective cross coverage.
Drives departmental strategy by analyzing key metrics and productivity data, identifying trends requiring rapid attention, and collaborating with stakeholders to implement real-time" solutions
Oversight and awareness of daily utilization review functions, including admission and continued stay reviews, appropriate level-of-care determinations, and pre-bill denial interventions
Serves as regional regulatory expert, monitoring policy changes, identifying trends requiring escalation, and maintaining compliance with state specific regulations including reimbursement structures, Medicaid requirements, and review protocols.
Manages UR RN float pool for region and ensures operational efficiencies and continuity across hospitals, including during volume surges, staff leave, or transitions.
Participates in the development of systemwide goals, policy updates, and technology implementations impacting utilization management. Leads initiatives to support department strategy, i.e., length of stay, observation conversion, timely reviews, and complex clinical cases by monitoring and reporting regional utilization metrics.
Serves as the primary contact for hospital executive and clinical leadership in the designated region, aligning utilization management strategies with local needs under the direction of senior leadership while promoting efficiency and regulatory compliance
Performance management of staff including float pool, ensuring licensure, competencies, and annual performance reviews.
Leads UM Committee, in partnership with physician advisor, for each hospital within region. Ensures connectivity and cadence of communication with each ACM Director, Physician Advisor, and CMO at each site. Responsible for escalations and connectivity to long length of stay and complex discharge team, as well as revenue cycle management.
Facilitates cross-functional collaboration with discharge planning / care coordination, physician advisors, and medical staff to optimize resource use.
Provides training, mentorship, and professional development opportunities for UR teams, supporting retention, engagement, and high performance. Leads onboarding and orientation, in partnership with other key leaders, for all new hire UR RNs.
Leads ongoing education and competency of entire UR RN team ensuring quality reviews and criteria usage. This includes interrater reliability, Sitel modules, Compass education modules, and updates to MCG and InterQual.
Ensures compliance with CMS guidelines, commercial payor requirements, and accreditation standards (i.e. Joint Commission)
Provides clinical assessment, evaluation, and disposition of persons presenting with behavioral health concerns or illness.
Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
Participates in multi-disciplinary quality and service improvement teams.
CUSTOM.PRIMARY.DUTIES.RESPONSIBILITIES.ADDENDUM
Minimal Qualifications
Education
Experience
Licenses and Certifications
Knowledge, Skills, and Abilities
This position has a hiring range of $142,064 - $287,996
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