Manager of Utilization and Denial Management

WOOSTER COMMUNITY HOSPITAL JOB DESCRIPTION

Manager of Utilization & Denial Management

MAIN FUNCTION:

Under the direction of the Director of Revenue Cycle and in collaboration with the Revenue Cycle Physician Liaison, the Manager of Utilization & Denial Management is responsible for managing the day-to-day operations of the Utilization Management Program and team. The Manager oversees all phases of Utilization Management projects including development, planning and implementation. The Manager will also be responsible for initiatives, workflows and processes to enhance quality-driven outcomes. The Manager is expected to monitor activities that include overutilization, underutilization, and standardization including clinical precertification, medical necessity and prior authorization requirements and while helping the organization reduce the volume of payment/status denials in collaboration with both financial and clinical leadership.

RESPONSIBLE TO: Director of Revenue Cycle

POSITION REQUIREMENTS:

• RN (with active Ohio license)
• 5 years experience in Utilization Management
• Bachelors degree in nursing, or equivalent experience
• Clinical experience in an acute care setting
• Ability to effectively communicate both orally and in writing
• Facilitate rapid problem resolution
• Ability to work as a change agent with process improvement teams, management and medical staff
• Analytical ability to evaluate problem situations in-depth and come to independent, appropriate decisions
• Ability to multitask and meet deadlines
• Proficient in process improvement methodology, such as Lean or Six Sigma training
• Proficient computer skills, including Meditech Clinical Documentation Review, Microsoft Access, Excel and Word with ability in designing data with spreadsheets, tables and run charts
• Demonstrated leadership abilities with the capacity to motivate and inspire a team towards achieving organizational goals
• Must have a detailed understanding of third-party payer reimbursement

POSITION EXPECTATIONS:

• Provides oversight to the UM functions assuring compliance with regulatory agencies and third-party payers
• Provides denial oversight, develops and executes strategic improvement initiatives around technical and clinical/medical necessity denials to identify trends and opportunities for improvement to reduce occurrences
• Facilitates the UM Committee, providing statistics and identifying trends and opportunities for improvement
• Creates action plans, in cooperation with the clinical managers and medical staff, and revenue cycle leadership to improve processes for identification as error prone and not standardized. Facilitates process improvement through application of the DMAIC process improvement methodology
• Provides communication to physicians and appropriate staff related to opportunities for improvement related to utilization management and/or denials
• Utilizing Lean methodology, identifies opportunities to reduce re-work and waste and improve efficiencies in all processes and levels of the organization
• Communicates, facilitates and works to offer pro-active collaboration of problem-solving solutions with people at all levels of the organization as well as provider networks and vendors.
• Assists in developing utilization management recommendations and assessment initiatives through medical staff departments, PI teams and/or service lines in order to evaluate effectiveness and potential opportunities for improvement
• Manages the UM personnel assuring timely and accurate clinical data submission as well as follow up to denials
• Establishes a working relationship with department managers and physicians providing them with timely acquisition of information/data as needed.

Created: 1/28/25

Approved: TMMYERS