Utilization and Denials Management Auditor

External Job Title: Utilization and Denials Management Auditor

Capability: Healthcare

Business Unit: Huron Managed Services

Level:

Reports To: Supervisor/Manager/Director, Utilization and Denials Management

Work Location: Microsourcing Office, Taguig, Philippines

Work Shift: PH Night

POSITION SUMMARY:

Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes.

Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients.

Joining the Huron team means you’ll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise.

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: Atleast 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: Bachelor of Science in Nursing.

• Licensure: Must be Registered Nurse and with active PHRN or 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.

• Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)

• 
  
  

Preferred Qualifications:

• Education: Master’s degree or credential in business, healthcare, or related field 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)

• Soft Skills:

  • Ability to pay close attention to details; strong follow-up and follow-through skills

  • Regularly makes complex decisions within the scope of the position, and is comfortable working independently

  • Requires the use of independent judgment, discretion and decision-making abilities

  • Demonstrates teamwork and integrity in all work-related activities

  • Ability to interact with internal and external customers in a professional manner

  • Strong analytical and critical thinking skills.

  • Experience in a matrixed environment

  • Excellent written and verbal communication skills; ability to create impactful presentations