Director of Clinical Review Management

At St. Luke’s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke’s is truly a great place to work.The Director of Clinical Review Management provides strategic and operational leadership across multiple settings and operating units to lead the organization's utilization management function in support of SLHS mission, vision, and strategic objectives.What You Can Expect:Provides overall strategic direction and oversight of the day to-day operations of utilization programs to meet hospital, system and network utilization goals while maintaining high quality of care and outstanding customer satisfactionResponsible for utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes. Monitors the organizational utilization of services and optimize reimbursement for the organization while maximizing use of the patient's provider benefits for their needsCollaborates with providers, care management, case management, revenue cycle, denials and appeals, and other groups to manage the total cost of care through the development and execution of clinical and operational programs to manage costs and ensure quality care delivery.Experience managing large teams, experience in change management, process improvement with compliance and CMS at the forefrontKnowledge of denial management and MCG/IQ experienceQualifications:Education: Bachelors' Degree in Nursing or Master's Degree in a healthcare related field.Experience: 8 years experienceRN strongly preferredPlease contact Julie @ questionsAt St. Luke’s, caring for people in the communities we serve is our mission - and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.

Created: 2025-10-08