Denials and Utilization Review Manager

Santa Barbara, California
Health & Social Care, Practitioner & Technician (Healthcare Practitioners and Technical Occupations)
Job Type
Working Hours
8:00 AM - 5:00 PM
US$ 48.00 - US$ 52.00 per hour
Ref. Number
Costanza, Daniel S., Spherion
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Job Description

Under the general direction and guidance of the Director of Revenue Integrity, the Manager of Denials & Appeals is responsible for the overall management of denials and appeals between our organization and outside payers. The manager is also responsible for concurrent utilization review and management of patients within a Health Care system. Our ideal candidate will serve 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 our business 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.

Working hours: 8:00 AM - 5:00 PM

Our highly skilled candidate 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. Our ideal candidate will aslo be able to exercise independent discretion and judgement, and act at all times with the highest degree of professionalism and objectivity.
Candidate 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.
Candidate must also posses knowledge of various spreadsheet applications related to billing requirements and charges. Knowledge of including Microsoft Word and Excel is extremely important.


1-4 years

Qualified candidate must posses a Bachelor's degree in Business, Accounting, Finance, Nursing, or other related field. Our ideal candidate must also hold a current nursing license in good standing. If you have a not an active California nursing
license, you would need to become certified in California upon hire. Our client also prefers a candidate with Certification in case management. Our client also requires: Two years direct patient care experience as an RN in an acute care setting. Three years
years of experience working with denials and appeals, utilization review, and case management in an acute care setting. Two years supervisory experience.

If you are interested in this extended contract position. Please apply to this job posting with your most current resume or contact our office immediately. Thank you.

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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