Executive Director, Utilization Management

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Executive Director of Utilization Management (UM) provides strategic and operational leadership for the enterprise UM program across all Beth Israel Lahey Health (BILH) facilities. This role will lead the transformation of UM operations from a decentralized model to an integrated, centralized enterprise function with standardized processes, shared best practices, and consistent performance across all facilities. This executive-level position is responsible for developing and executing comprehensive utilization management strategies that ensure appropriate care delivery in the most clinically and financially optimal settings while maintaining regulatory compliance and optimizing reimbursement. The Executive Director partners with senior clinical and operational leaders, including the Chief Nursing Officers, Chief Medical Officers, Physician Advisors, and payer partners, to align UM initiatives with organizational goals of care coordination, length of stay optimization, and denial prevention while managing UM directors and staff across the system.

Job Description:

Essential Duties & Responsibilities, including but not limited to:

Strategic Leadership & Program Development:

• Develop and execute enterprise-wide UM strategic plans aligned with BILH's clinical, financial, quality, and population health objectives
• Lead the evaluation, selection, and management of UM vendor partnerships and technology solutions, including InterQual, MCG, or other medical necessity criteria platforms
• Design and operationalize standardized UM policies, procedures, and best practices across all BILH facilities, leading the transition from decentralized site-based operations to an integrated enterprise model while ensuring compliance with CMS Conditions of Participation
• Serve as executive sponsor for the Utilization Management Committee and lead the annual review and implementation of the system-wide Utilization Management Plan
• Drive innovation in care coordination models that support value-based care initiatives and alternative payment models
• Establish strategic payer relationships to optimize authorization processes and reduce administrative burden

Enterprise Integration & Standardization:

• Lead the strategic evolution of UM operations from facility-based models to a centralized, standardized enterprise function
• Assess current state UM practices across all 15 hospitals to identify opportunities for standardization, efficiency gains, and best practice adoption
• Develop and implement a comprehensive change management strategy to transition facilities to standardized UM workflows, policies, and performance expectations
• Create governance structures that balance enterprise consistency with facility-specific clinical needs
• Build consensus among site-based leadership teams to adopt centralized UM processes and shared service models
• Establish standardized work queues, case assignment methodologies, and productivity expectations across the system
• Design communication strategies to support cultural shifts from site autonomy to enterprise integration
• Develop phased implementation plans that minimize disruption while achieving standardization goals
• Create feedback mechanisms to ensure facility voices are heard throughout the centralization process

Regulatory Compliance & Quality Oversight :

• Ensure enterprise-wide compliance with CMS Conditions of Participation for Utilization Review and Discharge Planning across all 15 hospitals
• Oversee compliance with Two-Midnight Rule, Observation services guidelines, and all applicable federal and state regulations
• Lead organizational response to regulatory changes, RAC audits, payer audits, and external reviews
• Collaborate with Compliance, Legal, and Quality departments to address utilization management-related risks and findings
• Monitor and report on quality metrics related to avoidable days, unnecessary admissions, and readmission prevention
• Develop and implement denial prevention strategies based on comprehensive root cause analysis of authorization and medical necessity denials

Financial & Operational Excellence:

• Oversee UM operations across the continuum of care with accountability for length of stay optimization, appropriate level of care placement, and denial reduction
• Drive measurable financial impact through reduced avoidable days, improved observation-to-inpatient conversion appropriateness, and authorization denial prevention
• Monitor and analyze the financial impact of UM decisions, including wr