The Utilization and Denials Management Auditor is responsible for the day-to-day production and quality functions of a team of Utilization and Denials Management specialists specializing in meeting client production goals and accuracy goals. The Auditor assists Utilization and Denials management in preparing daily operational reports, provide QA (quality assurance) feedback, and participate in the client interactions and internal stakeholder meetings.
KEY RESPONSIBILITES:Quality Assurance (QA) & Delivery- Assists in QA program build, including advising on the most critical aspects of the workflow/accounts to audit, attributes of an effective audit program, and how to leverage automation/efficiency tools
- Monitors performance of all Utilization and Denials Management staff using key metrics including, but not limited to Utilization Management and Clinical Denials & Appeals productivity and accuracy performance.
- Escalate Production and QA concerns or roadblocks to the Manager for involvement as needed. Work closely with the Training teams members to communicate progress across the Team to the Manager.
- Demonstrates domain expertise in quality process related to meeting production schedules and the documentation of medical diagnoses and treatment practices
- Deep understanding of both the production and quality assurance Utilization and Denials Management process and guidelines.
QA Administration & Documentation- Experience providing training, coaching, and development to team members, as well as providing regular feedback regarding work performance
- Monitors and maintains team QA records and auditing/education findings for Utilization and Denials Management staff.
- Completes any special projects, such as full Utilization and Denials Management audit, and other duties as assigned in a timely manner.
- Mentors staff to maximize performance and potential.
- Assist in maintaining and monitoring team members' job satisfaction and morale.
Performance & Evaluation- Reviews both production and quality accuracy reporting and/or system reports on progress for all assigned projects and share feedback
- Motivates team members through effective training and coaching to improve quality and professionalism on work assignments. Conducts monthly team meetings and annual performance evaluations with team members.
Collaboration & Stakeholder Management- Partner with global Operations, Training, and HR to streamline onboarding and on-the-job learning (OJL).
- Participate in client calibration calls to align training KPIs with operational metrics.
- Support client visits, internal audits, and process reviews by presenting training dashboards and achievements.
Other duties and responsibilities as assigned. QUALIFICATIONS: Required Qualifications:- QA Experience: At least 1 year of Utilization management and/or Clinical appeals writing QA or auditing experience in healthcare setting.
- Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience.
- Education: Associate Degree in Nursing (ADN) or Diploma in Nursing.
- Licensure: Must be Registered Nurse and with active USRN license.
- RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
- Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
Preferred Qualifications:- Education: Science in Nursing (BSN) preferred
- Credential/Certification: Case management or clinical appeals or clinical denials certification (ACMA) is preferred.
- Software Knowledge: Proficiency with using computer programs for tracking authorization, and/or denials and appeals . Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)
Additional Job Description
The estimated base salary range for this job is $80,000 - $105,000. The range represents a good faith estimate of the range that Huron reasonably expects to pay for this job at the time of the job posting. The actual salary paid to an individual will vary based on multiple factors, including but not limited to specific skills or certifications, years of experience, market changes, and required travel. The job is also eligible to participate in Huron's benefit plans which include medical, dental and vision coverage and other wellness programs. The salary range information provided is in accordance with applicable state and local laws regarding salary transparency that are currently in effect and may be implemented in the future.
Position LevelAssociate
CountryUnited States of America
