OverviewThe UM Manager, Denials and Payer Relations provides operational leadership and oversight for enterprise-wide utilization management activities related to authorization management, medical necessity compliance, denial prevention, denial trends, payer escalation, and payer relationship management. This position serves as the primary liaison between Utilization Management, Revenue Cycle, Clinical Operations, Physician Advisors, Managed Care Contracting, Patient Financial Services, and external payers to ensure accurate clinical review processes, timely authorization management, reduction of preventable denials, and optimization of reimbursement. The manager is responsible for developing and implementing strategies to improve medical necessity compliance, decrease avoidable denials, support successful appeals, monitor payer performance, and establish collaborative relationships with commercial, governmental, and managed care organizations across the enterprise. This role utilizes data analytics, regulatory expertise, and interdisciplinary collaboration to drive performance improvement initiatives that support organizational quality, compliance, operational, and financial goals.
QualificationsEducation- Bachelor's degree in nursing.
- Master's degree in nursing, Healthcare Administration, Business Administration, or related field preferred.
Experience- Minimum five (5) years of Utilization Management, Case Management, Revenue Cycle, or Denials Management experience.
- Minimum three (3) years of leadership experience managing hospital UM operations.
- Experience leading multi-site or enterprise-wide coding operations preferred.
- Experience working with Medicare, Medicaid, and commercial payers.
- Experience analyzing denial and authorization data.
- Experience with complex health system or academic medical centers is strongly preferred.
- Epic experience a must.
- Knowledge of claims processing, denials management, and reimbursement analysis.
- Ability to interpret regulatory requirements and translate them into operational processes.
- Ability to manage multiple priorities and lead through organizational change.
License/Certification/Registration- Registered Nurse (RN) required.
- Prior Authorization Certified Specialist (PACS) preferred.
- Accredited Case Manager - Registered Nurse (ACM-RN) preferred.
- Certified Case Manager (CCM) preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Certification in Healthcare Quality and Management (HCQM) preferred.
- Certified Professional in Utilization Review (CPUR) preferred.
- Clinical Medical Assistant Certification (CMAC) preferred.
- Certified Revenue Cycle Representative (CRCR) preferred.
