Job Description

Responsible for the planning, organization, and daily operations of the Utilization Review (UR) program to ensure accurate patient status determination, regulatory compliance, and optimal reimbursement. Provides direct supervision and leadership for the Utilization Review team while collaborating closely with physicians, Patient Status Officers (PSOs), Case Management, Coding, Clinical Documentation Integrity (CDI), and Revenue Cycle teams to ensure patients are assigned the appropriate level of care prior to discharge.

Directs concurrent medical necessity reviews using nationally recognized evidence-based criteria, including InterQual®, MCG®, and applicable commercial payer medical necessity guidelines, to support appropriate inpatient, observation, and outpatient status assignment. Monitors payer-specific authorization requirements and collaborates with commercial and governmental payers to proactively resolve patient status issues, minimize denials, and improve reimbursement outcomes.

Oversees secondary utilization reviews, payer escalations, peer-to-peer review coordination, medical necessity reconsiderations, and concurrent status appeals. Performs complex medical record reviews and provides clinical recommendations to support appropriate status determinations based on documented clinical evidence.

Maintains and updates the CMS-required Utilization Review Plan and ensures compliance with all applicable CMS Conditions of Participation, commercial payer requirements, and federal and state regulatory standards. Develops departmental policies, auditing processes, performance metrics, and staff education to promote regulatory compliance and continuous quality improvement.

Analyzes utilization trends, payer denials, avoidable observation conversions, and length-of-stay opportunities to improve operational performance and reduce post-discharge status denials. Partners with Patient Care Services, Transfer Center, Physician Leaders, Revenue Integrity Patient Financial Services, and Managed Care to support middle revenue cycle initiatives that improve revenue capture, reduce reimbursement risk, and enhance payer relationships.

Develops departmental goals, staffing plans, productivity standards, and annual operating budgets while monitoring financial performance and departmental outcomes. Promotes a collaborative, data-driven environment focused on regulatory compliance, patient status accuracy, operational efficiency, and physician and payer engagement.

Service Excellence: All team members of Southeast Georgia Health System will promote service excellence by developing and maintaining positive relationships with customers, other team members, and the medical staff and will ensure the highest quality of care by performing their responsibilities according to the highest professional standards.