Director of Utilization Management - Full Time

Education/Exp: RN, BSN with 10+ years of clinical experience. Expertise: MCG or InterQual Certified; expert in CMS, NJ Medicaid, and commercial payer policies. Certification in use and instruction required. Excel, Copilot, data analysis, and tracking and reporting productivity. Systems: Strong proficiency in MCG or like tool and PBO Super User. Leadership: Ability to partner across multidisciplinary workgroups (MDs, PAs, Surgeons, IT, and Registration) to drive clean timely compliant daily claims processing.

POSITION SUMMARY

• Compliance Ownership: Serve as the primary owner for sustaining compliance in accordance with CMS.gov guidelines. Lead the Utilization Review Committee and manage partnership with Physician Advisors to ensure clinical and regulatory alignment with PCRM quarterly sessions.
• Regulatory & Policy Alignment: Ensure all UM activities strictly adhere to CMS, NJ Medicaid requirements, and evolve commercial payer policies to prevent technical denials.
• LOC & IPO Management: Coordinate daily Level of Care (LOC) and support Inpatient Only (IPO) workgroup, compliant surgical placement, and revenue protection.
• Performance Monitoring: Actively monitor department dashboards; identify trends and execute corrective action plans when metrics deviate from targets.
• Integrated CDI: Create the foundations and Lead Outpatient CDI in Observation settings and collaborate with Quality, Sepsis, and CDI teams
• Education: Train MD/RN teams and partner with new hire orientation to socialize on Inpatient criteria and appropriate use AI-driven identification tools.

• Payer Alignment & Approvals: Complete initial and continued stay reviews within 24 hours to ensure payer awareness, maximize authorization rates, and reduce retrospective denials.
• Length of Stay (LOS): Maintain average LOS at or below the GMLOS through aggressive barrier removal and timely discharge planning partnered with CM and D/C planning.

• RN, CPC, CDIC, CRCS, MCG or InterQual Certified; expert in CMS, NJ Medicaid, and commercial payer policies.

  Certification in use and instruction required.

  Excel, Copilot, data analysis, and tracking and reporting productivity

Total Rewards at AtlantiCare

At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including:

Generous Paid Time Off (PTO)

Medical, Prescription Drug, Dental & Vision Insurance

Retirement Plans with employer contributions

Short-Term & Long-Term Disability Coverage

Life & Accidental Death & Dismemberment Insurance

Tuition Reimbursement to support your educational goals

Flexible Spending Accounts (FSAs) for healthcare and dependent care

Wellness Programs to help you thrive

Voluntary Benefits, including Pet Insurance and more

Benefits offerings may vary based on position and are subject to eligibility requirements.

Join a team that values your well-being and invests in your future.