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This role is responsible for the oversight of third-party payer utilization review (UR) and the denial management (DM) process.

• The Manager functions as an appeal/denial expert and takes an active role in managing the process for regional sites and coordinating with Corporate Utilization review and denial management / Appeals team.
• Provides supervision and direction for UR process along with analysis, resolution, monitoring & reporting of clinical denials.
• Facilitate peer-to-peer communication with payers and coordinate with physician advisors for denial management purposes.
• Keeps abreast with the ongoing education/training to stay current with emerging industry trends on utilization review and denials management in addition to maintaining and updating payor matrix with payor specifics.
• Serves as a liaison between admitting, Case management, Business office, coding teams to ensure timely reporting and tracking/ follow up of denials.
• Demonstrates appropriate knowledge of payer contract changes as they pertain to level of care determination and the appeal/denial process.
• Reviews and determines appropriate strategy in response to reimbursement denials.
• Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration/ CMO and the Utilization Review Committee wherever applicable.
• Participate in regular Utilization committee and Case management meetings with stakeholders from all departments for regional sites and corporate leadership team to provide necessary education and discuss progress and protocols for Insurance authorization and denial prevention strategies.
• Performs ongoing audits, to monitor UR and appeal/denial process and develops process improvement plans for identified deficiencies.
• Able to work independently and use sound judgment. 
• Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment.
• Performs other duties as assigned.

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1.          Medical Graduate, Dental Graduate or Nursing Graduate or related healthcare required professional.

2.          Minimum of 3 years’ experience in Utilization review / Denial management process.

Preferred qualifications:

1.                ECFMG Certification And/or Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.

2.                Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes; ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare                               disciplines; program and database development a plus

3.                1+ year of clinical experience in acute care setting preferred.

4.                Excellent written and verbal communication skills. Excellent critical thinking skills.

5.                Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.