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Posted: 19-Jun-25
Location: Gainesville, Georgia
Type: Full Time
Sector:
Required Education:
Internal Number: R20509
Job Summary
The Director of Utilization Management (UM) and Clinical Documentation Improvement (CDI) is responsible for leading and managing the Utilization Management (UM) and Clinical Documentation Improvement (CDI) functions at Northeast Georgia Medical Center. This position plays a critical role in ensuring documentation accuracy, optimizing reimbursement, minimizing denials, improving case mix index (CMI), and ensuring appropriate utilization of hospital resources. The Director works collaboratively with hospital leadership, physicians, case management, finance, and compliance teams to enhance quality reporting, patient outcomes, and financial integrity.
This role serves as a key liaison between clinical and financial operations, ensuring a seamless integration of documentation integrity with utilization management to drive efficiency, compliance, and revenue cycle optimization.
Job Specific and Unique Knowledge, Skills and Abilities
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Proven ability to lead teams, manage budgets, and implement strategic initiatives.
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Strong ability to educate and influence physicians, staff, and leadership on CDI and UM best practices.
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Experience in data analysis, KPI tracking, and performance improvement strategies.
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Expertise in coding and DRG reimbursement, case mix index (CMI) optimization, payer regulations, and revenue cycle principles.
Essential Tasks and Responsibilities
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Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards.
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Oversee and manage the CDI department to ensure ongoing accuracy, completeness, and specificity of clinical documentation.
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Work closely with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance.
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Monitor and analyze key performance indicators (KPIs), financial goals, and length of stay (LOS) metrics to drive performance improvements.
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Recruit, train, and manage a high-performing CDI and UM team, ensuring operational alignment with hospital objectives.
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Manage departmental budgets, ensuring financial responsibility and resource allocation
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Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement.
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Foster strong relationships with internal and external stakeholders, including hospital executives, physicians, and payers.
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Provide data-driven insights and strategic recommendations to hospital leadership regarding CDI and UM performance.
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Act as the operational leader for process improvement initiatives related to documentation, utilization management, and revenue cycle optimization.
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Work closely with Physician Advisors to develop and revise policies and procedures related to clinical status determination, medical necessity, clinical documentation, denials and appeals, and physician education.
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Provides education to operational leaders, staff and Physicians on the importance of the Clinical Documentation Improvement Program (CDIP), and works cooperatively with them to ensure that improved documentation is seen as part of the strategic mission of the Organization
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Facilitates modifications to clinical documentation through extensive concurrent interactions with Physicians, nursing staff, case managers, and coding team to ensure that appropriate reimbursement and severity of illness (SOI) is captured.
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Coordinates, complies and share data reflecting the activity associated with the Documentation Program on an on-going basis highlighting key performance indicators.
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Act as operational leader for Clinical Documentation Improvement Initiative with The Advisory Board to achieve "best practice" across the System, partnering with the medical staff, including Hospital employed Physicians and independent Physicians providers in the community.
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Review daily, weekly and monthly reports to monitor and analyze performance of UM and CDI departments, assess data against KPI standards and goals, and identifies trends to make adjustments as indicated. Keeps leadership, staff, and clinical staff (where appropriate) informed.
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Oversees UM working closely with Case Management and other members of the interdisciplinary team to ensure effective collaboration for length of stay and throughput.
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Communicate with and educate physicians and other key stake holders regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care.
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Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently.
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Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/physician performance and anticipating payer and managed care demands.
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Actively participates as the operational leader for UM and CDI in committees including but not limited to MRUR; Compliance; Policy and Procedures; and Quality
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Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
Minimum Job Qualifications
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Licensure or other certifications: Current Registered Nurse license in the State of Georgia.
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Educational Requirements: Bachelor's Degree in Nursing
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Minimum Experience: Minimum of 7 years UR and CDI experience combined, with progressive Revenue Cycle leadership experience of 2 or more years.
Preferred Job Qualifications
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Preferred Licensure or other certifications: UR specific certification preferred (CCM, ACM, CPUR); CDI/coding certification desirable
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Preferred Educational Requirements: Master's Degree in Nursing or other health related field