Director, System Utilization Management

LCMC Health•Irvine, CA

2d•Onsite

About The Position

The Director, System Utilization Management (UM) provides strategic and operational leadership for utilization review, and resource management functions across the health system. This role ensures appropriate use of healthcare services, regulatory compliance, and optimal reimbursement, across all facilities and service lines. The Director oversees day-to-day utilization review operations, establishes standardized processes and best practices, and drives organizational alignment to promote cost-effective care. Working collaboratively with clinical, operational, and revenue cycle leadership, this position advances performance improvement initiatives, reduces denials, and strengthens financial and regulatory outcomes across the system.

Requirements

Bachelor’s degree in nursing, required
7–10+ years of progressive leadership experience in Utilization Management or Case Management.
Strong knowledge of payer requirements, CMS regulations, and accreditation standards.
In depth working knowledge and experience of the EPIC Electronic Health Record System Utilization Management workflows, WQs and data reporting capabilities.
Active RN license (if clinical background).

Nice To Haves

Master’s degree preferred.
Experience in multi-hospital or system-level leadership preferred.
Certification in Case Management and/or Utilization Management preferred.

Responsibilities

Develop and implement a system-wide utilization management strategy aligned with organizational goals.
Lead standardization of UM processes across hospitals.
Collaborate with executive leadership and Case Management to reduce denials, prevent avoidable days, and optimize length of stay (LOS).
Identify trends and implement performance improvement initiatives to enhance clinical and financial outcomes.
Develop a culture of high performance and continuous improvement that values learning and a commitment to quality, including conducting routine, ongoing audits to ensure with UM established policies and procedures.
Ensure compliance with federal, state, and payer regulations along with all relevant accreditation and regulatory requirements.
Oversee adherence to InterQual or MCG criteria for medical necessity determinations.
Ensure compliance with third party payor requirements, both governmental and commercial payors.
Partner with Revenue Cycle, Finance, and Managed Care teams to reduce payer denials and improve reimbursement.
Monitor denial trends and lead root cause analysis and corrective action plans.
Oversee appeals processes and ensure timely documentation to support medical necessity.
Collaborate with the Physician Advisor Team to both reduce denials and identify areas for clinical documentation improvement; collaborate with the Clinical Documentation Integrity Team (“CDI”) on documentation improvement initiatives.
Direct inpatient and outpatient utilization review activities.
Ensure effective communication between physicians, nursing, and payers.
Analyze system-level data including but not limited to LOS, readmissions, avoidable days, denial rates, and throughput.
Develop dashboards and KPIs to track performance.
Lead multidisciplinary committees focused on utilization and throughput optimization.
Provide direct oversight to UM manager and clinical review staff.
Establish productivity benchmarks and quality standards.
Mentor leaders and promote professional development.