Denials and Utilization Review Manager

Santa Barbara, California
Accounting & Auditing (Business and Financial Operations Occupations)
Job Type
Working Hours
9:00 AM - 5:00 PM
US$ 120,000 - US$ 145,000 per year
Ref. Number
Nyeche, Jenny, Spherion
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Job Description

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.

1. Leadership Activities: Manages the Denials, Appeals and Utilization Review staff and their activities. Responsible for completion of performance evaluations, providing work direction and training, establishing goals, process improvement, productivity management, ensuring completion of assignments, tracking work to key performance indicators and industry benchmarks and best practices, and approval/validation of timekeeping records.
2. Communication: Serves as a liaison and resource to other revenue cycle departments and other appropriate stakeholders for receiving, reviewing and managing utilization review, and denial and appeal inquiries referred to the team for support. Delegates tasks appropriately to members of the team and/or completes tasks as necessary to support Cottage Health leadership.
3. Process Improvements: In partnership with Patient Financial Services, Patient Access, Managed Care Contracting and Case Management leadership, the manager helps identify, coordinate, and lead projects that identify the root cause of denials and then take appropriate action to eliminate denials from occurring. Develops and maintains dashboards to report on results and track and trend performance over time. Ensures that project work and process improvement efforts lead to improved performance and results. Monitors, identifies and reports on suspected or emerging trends related to payer denials. Keeps current regarding efficient ways to manage denials, including the use of emerging technologies, as well as industry best practice, in order to avoid denials and maintain efficiency.
4. Quality and Education: In partnership with Managed Care Contracting leadership, facilitates education opportunities with providers and other stakeholders to decrease appeals and denials and improve quality to patients served. When negative payor trends are identified, works with case management leadership to facilitate focus meetings with appropriate payer representatives to isolate opportunities for improvement and identify clear action planning for correction. Provides routine education sessions to Patient Financial Services and Patient Access team members. Remains current with regulatory requirements and ensures compliance, and provides necessary education to others regarding requirements.

Working hours: 9:00 AM - 5:00 PM

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

Ideal candidate will 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. Working knowledge of regulations and provider contracts governing coverage of inpatient services, such as Medicare, Medi-Cal, and commercial payors.


4-7 years

If you feel that you are qualified for this position, respond to this posting or contact our office with your resume!

Spherion has helped thousands of people just like you find work happiness! Our experienced staff will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temp-to-perm or direct hire opportunities, no one works harder for you than Spherion. EEO Employer: Race, Religion, Color, National Origin, Citizenship, Sex, Sexual Orientation, Gender Identity, Age, Disability, Ancestry, Veteran Status, Genetic Information, Service in the Uniformed Services or any other classification protected by law. San Francisco Fair Chance Ordinance: Qualified applicants in San Francisco with criminal histories will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.

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