We are honored to share that all seven of our eligible hospitals have been named top performers in the 2025 Bernard A. Birnbaum, MD, Quality Leadership Rankings by Vizient Inc., a trusted national benchmark for hospital performance.
This year, five of our hospitals ranked in the top five of their …
Director Centralized Utilization Review
Location:
Hybrid, 701 S Fry Rd,
Katy,
TX 77450
- Job Ref:
- JR-1014
- Talent Area:
- Nursing Management
- Job Shift:
- Day
- Job Type:
- Full Time
At Houston Methodist, the Director Centralized Utilization Review (UR) position is responsible for strategic, administrative, and operational leadership for the Utilization Management (UM) department across the Houston Methodist system. This position oversees all aspects of utilization review to ensure medical necessity, level of care appropriateness, and compliance with CMS Conditions of Participation, payer requirements, and organizational policies. The Director Centralized UR position partners closely with physician advisors, case management directors, and revenue cycle leaders to prevent denials, streamline authorization processes, impact unnecessary length of stay for inpatient and observation services, and monitor appropriateness of resource utilization. This position integrates technology, evidence-based criteria, and performance analytics to achieve superior clinical, operational, and financial outcomes.
The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence, and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.
The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence, and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.
FLSA STATUS
Exempt
QUALIFICATIONS
EDUCATION
EXPERIENCE
LICENSES AND CERTIFICATIONS
Required
SKILLS AND ABILITIES
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
SERVICE ESSENTIAL FUNCTIONS
QUALITY/SAFETY ESSENTIAL FUNCTIONS
FINANCE ESSENTIAL FUNCTIONS
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
SUPPLEMENTAL REQUIREMENTS
Exempt
QUALIFICATIONS
EDUCATION
- Bachelor’s and Master’s degree, one of which is in nursing, or must be currently enrolled in a program to achieve Master’s degree within two years of hiring
EXPERIENCE
- Five years in case management with three years including utilization review, with two years in people management in a healthcare setting
- Expertise with nationally recognized medical necessity review guidelines
LICENSES AND CERTIFICATIONS
Required
- RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and
- Magnet ANCC-recognized certification
SKILLS AND ABILITIES
- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
- Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially about activities impacting patient or employee safety or security
- Demonstrates the ability to interact with others in a way that gives them confidence in one’s intentions and those of the organization
- Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one’s own behavior to accommodate tasks, situations and individuals involved
- Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills
- Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences
- Extensive knowledge of regulatory and accreditation agency requirements that impact department; stays abreast of industry changes
- Demonstrates highly effective communication skills—strong written communications and platform presentation abilities
- Ability to work effectively in a fast-paced environment
- Demonstrates flexibility and adaptability in the workplace
- Capable of leading teams/facilitating groups, building consensus and garnering highest confidence in professionalism and work product by senior leadership
- Ability to work under pressure and balance many competing priorities; highly responsive and solution/action oriented
- Proficiency in Microsoft Office Suite, InterQual preferred
- Maintains a positive and supportive attitude and demeanor
- Professional handling of exposure to confidential/sensitive information
- Excellent analytical skills
- Advanced negotiation and mediation skills
- Advanced time management and prioritization skills
- Expert collaboration skills
- Participation in ACMA, CMSA, or ACPA related professional organizations encouraged
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
- Directs, develops, and implements strategic and operational/high-level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives.
- Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service, and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees.
- Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators.
- Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes.
- Identifies opportunities and takes action to build strategic relationships between one’s area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed.
- Provides overall strategic direction and operational oversight for the centralized system-wide utilization review activities. Attends hospital-based UM Committees and reports on UR related activities. Collaborates with case management department, revenue cycle, quality, and managed contracting teams to ensure alignment of UM processes with organizational priorities.
- Partners closely with physician advisors to support medical necessity determinations and payer communications. Provides education and consultation to clinical and operational leaders on medical necessity and level-of-care criteria.
- Oversees the denials management clinical team for concurrent, retrospective, and self-denial processes. Recruits, trains, and mentors UM leadership and front-line staff to meet organizational goals. Oversees staffing models to ensure appropriate coverage for initial, concurrent, and retrospective reviews.
SERVICE ESSENTIAL FUNCTIONS
- Oversees department operations, designated projects, schedules, and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.
- Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department.
- Establishes policies, procedures, and best practices for utilization review in alignment with regulatory and payer standards. Implements and supports audit-readiness and compliance monitoring tools, policies, and training.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
- Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable.
- Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety.
- Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).
- Develops and monitors key performance indicators (KPIs) for medical necessity reviews, authorizations, denials prevention, denials rates and Candidate for Billing (CFB). Prepares and presents regular reports to senior leadership on UM performance, denial trends, and operational efficiencies.
- Analyzes utilization trends and collaborates with leadership to implement process improvements. Develops corrective action plans to address any identified compliance gaps or denials trends.
- Maintains readiness for payer audits. Ensures alignment with CMS, DNV, and state regulatory requirements across case management and UR processes. Maintains governmental notices and educates on appropriate delivery standards in collaboration with case management partners (ABN, HINN, CC44, MOON, IMM, MCSN.
FINANCE ESSENTIAL FUNCTIONS
- Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness.
- Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications.
- Actively participates in the managed contracting process to advise on utilization review language and setting expectations with payers. Serves as a resource for contract interpretation and supports negotiations related to payer utilization requirements.
- Monitors and supports team collaboration regarding non-medically necessary days for patients in custodial, extended recovery, observation, and inpatient level of care. Manages and ensures work queue performance is completed timely to avoid denials or billing delays. Provides oversight for the concurrent denials and short stay review process in collaboration with physician advisors. Implements strategies to reduce payer denials and appeals by improving front-end authorization processes and concurrent reviews.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
- Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings.
- Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate.
- Ensures own career discussions occur with appropriate management. Completes and updates My Development Plan (MDP) on an ongoing basis. Conducts conversations with staff on their development and MDP.
- Leverages technology platforms, predictive analytics, and real-time dashboards to enhance utilization management processes. Works with IT and analytics teams to develop reporting tools and automation solutions for efficiency and compliance.
SUPPLEMENTAL REQUIREMENTS
- WORK ATTIRE
- Uniform: No
- Scrubs: No
- Business professional: Yes
- Other (department approved): No
- On Call* No
- May require travel within the Houston Metropolitan area Yes
- May require travel outside Houston Metropolitan area No
ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
TRAVEL**
**Travel specifications may vary by department**
Company Profile:
Houston Methodist Continuing Care Hospital is a long-term acute care hospital that proudly serves the Greater Houston area, focused on the needs of patients requiring extended hospitalization. Located in Katy, west of the Texas Medical Center, Houston Methodist Continuing Care is committed to providing patients with the Houston Methodist standard of unparalleled quality and safety, focusing on the patient and family. The facility offers both inpatient and outpatient services, including hemodialysis or peritoneal dialysis, infectious disease management, intensive care, pain management, postsurgical complication management, pulmonary care management, trauma and neurological injury management, and outpatient rehabilitation therapies.
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