Manager Denials and Utilization Review

Revenue Cycle
Cottage Health
180000B1 Requisition #

Under the general direction and guidance of the Director of Revenue Integrity, the Manager of Denials & Utilization Review is responsible for the overall management of denials and appeals between Cottage Health and outside payers.  The manager is also responsible for concurrent utilization review and management of patients within Cottage Health.  This individual serves as a liaison and point of contact for all denial and appeal inquiries.

The manager actively manages, maintains and communicates denials and appeals activity to appropriate stakeholders.  This includes, but is not limited to, the compilation of management reports such as:  1) denials in progress, 2) wins/partial wins/losses, 3) cases where Cottage Health has elected not to appeal based on chart documentation/support, and 4) identified cases pending review.  Concurrent with these activities, the manager will identify and report on the categorization of denials, suspected or emerging trends related to payer denials and/or slow payment, and lead action planning for correction and process changes to eliminate avoidable denials.

As an active member of the Utilization Review Committee, the manager will regularly report on outcomes of utilization review, denials and appeals. The manager will also coordinate, monitor, implement, manage and report back on educational activities for performance improvement.  

Bachelor's degree in Business, Accounting, Finance, Nursing, or other related field.

Current nursing license in good standing. If not an active California nursing license, would need to become certified in California upon hire.  Certification in case management preferred.

Must be able to demonstrate an understanding of InterQual and Milliman guidelines, community standards relevant to inpatient acute care, and payer denial and appeal processes.

Must be able to exercise independent discretion and judgement, and act at all times with the highest degree of professionalism and objectivity.

Must be computer literate and able to manage Outlook, Word and Excel programs, prepare charts and graphs, and analyze data to identify trends and opportunities for process improvement.

Knowledge of various spreadsheet applications, including Microsoft Word.  Knowledge of billing requirements related to charges.  

Two years direct patient care experience as an RN in an acute care setting. Three years of experience working with denials and appeals, utilization review, and case management in an acute care setting. Two years supervisory experience.

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