Regional Director of Utilization Management

About Company:

We’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.

Read more here: https://ow.ly/YQ1C50WuRH1

This certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

Our benefits include:

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.

• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.

• Generous PTO – A robust paid time off policy to support work-life balance.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

At Bradford Health Services, we don’t just invest in our patients—we invest in our people.

About the Role:

The Regional Director of Utilization Management provides strategic and operational leadership for Utilization Management services across an assigned geographic region, ensuring patients receive timely access to medically necessary care while optimizing reimbursement through effective authorization management, concurrent review, medical necessity documentation, and payer collaboration. Reporting to the Vice President of Revenue Cycle, the Regional Director is responsible for the operational performance, quality, productivity, and financial outcomes of the Utilization Review functions within the assigned region. This leader provides direct oversight of Utilization Review Managers and Utilization Review Coordinators while partnering closely with facility leadership, physicians, nursing, therapists, Centralized Admissions, Patient Access, and Revenue Cycle teams to improve authorization outcomes, reduce medical necessity denials, support medically appropriate lengths of stay, and ensure compliance with payer and regulatory requirements. The Regional Director serves as the operational expert for Utilization Management and is responsible for implementing standardized workflows, monitoring performance metrics, coaching leaders, and driving continuous process improvement throughout the assigned region. 

Minimum Qualifications:

• Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, Social Work, or related healthcare field required.
• Minimum seven (7) years of progressive Utilization Management, Case Management, Revenue Cycle, or Behavioral Health leadership experience.
• Minimum three (3) years leading multi-site teams.
• Demonstrated Behavioral Health and/or substance use disorder (SUD) treatment experience required.
• Experience managing concurrent review, medical necessity, payer authorizations, appeals, and utilization management operations.
• Strong knowledge of commercial, Medicare, Medicaid, and VA authorization requirements.

Preferred Qualifications:

• Master's degree in Nursing, Healthcare Administration, Business Administration, Public Health, or related field.
• Certification in Case Management (CCM).
• Knowledge of ASAM Criteria and behavioral health medical necessity guidelines.
• Experience with enterprise EMR systems and reporting platforms.

Responsibilities:

• Provide regional operational leadership for Utilization Management across assigned facilities.
• Directly supervise Utilization Review Managers.
• Establish accountability for quality, productivity, timeliness, and financial performance.
• Ensure consistent implementation of enterprise Utilization Management standards.
• Monitor staffing levels and workload distribution to optimize productivity and patient outcomes.
• Oversee initial authorization and concurrent review activities.
• Ensure timely submission of clinical documentation to payers.
• Monitor authorization status to minimize interruptions in patient care.
• Collaborate with clinical teams to maximize medically appropriate authorized days.
• Escalate complex authorization issues as appropriate.
• Promote accurate and complete clinical documentation supporting medical necessity.
• Partner with physicians and clinical leadership to improve documentation quality.
• Monitor trends related to authorization denials and documentation deficiencies.
• Collaborate with clinical teams to improve documentation practices.
• Oversee appeal strategy for medical necessity denials.
• Support peer-to-peer review processes.
• Identify payer trends and develop regional action plans.
• Build collaborative relationships with payer representatives.
• Participate in payer meetings and operational reviews.
• Monitor regional performance metrics including:
  • Authorization approval rate
  • Initial authorization timeliness
  • Continued stay (concurrent review) approval rate
  • Medical necessity denial rate
  • Appeal overturn rate
  • Average approved Length of Stay
  • Revenue at Risk
  • Productivity
  • Quality audit scores
• Develop corrective action plans when performance targets are not achieved.

Skills:

The required skills enable the Regional Director of Utilization Management to provide strategic leadership across multiple facilities while ensuring operational excellence, regulatory compliance, and optimal reimbursement outcomes. Expertise in utilization management, concurrent review, medical necessity documentation, payer authorizations, and appeals supports effective collaboration with physicians, clinical teams, and payer representatives to improve authorization outcomes and reduce denials. Strong leadership, analytical, and performance management skills allow the Regional Director to oversee multi-site teams, implement standardized workflows, monitor key operational metrics, and drive continuous process improvement. Knowledge of commercial, Medicare, Medicaid, and VA payer requirements, along with experience using enterprise EMR systems and reporting platforms, supports data-driven decision-making, financial performance, and high-quality patient care across the region.