About the job Utilization & Denials Management Supervisor
APPROVED SIGN ON BONUS: PHP 75,000
External Job Title: Utilization & Denials Management Supervisor
Capability: Healthcare
Business Unit: Huron Managed Services
Level:
Reports To: Manager, Utilization & 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 & Denials Management Supervisor is responsible for the day-to-day production, initial and concurrent clinical reviews and quality functions of a team of Utilization & Denials Management staff. This role ensures accuracy in utilization management up to and including, the review of the claims denied and carry out the appeals process appropriately and in a timely manner. Plans, directs, supervises and evaluates feedback workflows and coordinates activities across all Utilization & Denials Management staff assigned to the team.
KEY RESPONSIBILITES:
Operational Oversight:
Supervise and support Clinical Denials & Appeals and UR staff including hiring, onboarding, scheduling, and performance management.
Monitor Clinical Denials & Appeals and UR productivity, accuracy, and related operational metrics.
Ensure timely resolution of clinical denials and appeals and UR issues.
Monitor daily workflows to ensure SLAs and KPIs (e.g., productivity, accuracy, and turnaround time). Adjusts work assignments as needed to ensure high risk populations are addressed timely and avoid backlogs.
Create action plans when metrics or performance is not meeting standards
Responsible for resolving at risk accounts escalated from staff in accordance with client policies
Implement process improvements to enhance efficiency and reduce denials and write-offs
Ensure timely resolution of Utilization & Denials Management related escalations.
Monitor and ensure departmental budget compliance
Effective and efficient organization and planning with the proven ability to manage complex multi-workstream performance improvement projects or multiple concurrent client engagements, while delegating and overseeing the work of junior team members
May be responsible for creating or participating in the creation of client facing metric scorecards and/or dashboards
Quality & Compliance:
Conduct Utilization Management and Clinical Denials & Appeals audits and accuracy reviews as needed, ensuring compliance with payer regulations.
Address Clinical Denials and partner with billing and A/R teams to identify root causes.
Stay current with Utilization Management and Clinical Denials updates and disseminate guidance to staff.
Ensure Utilization Management, Clinical Denials & Appeals policies & procedures are current and reflect the most compliant/accepted practices for medical coding.
Collaboration & Support:
Effectively communicate team's performance in Operations Meeting including reporting on KPIs, progress, and opportunity areas.
Work closely with HIM, Revenue Integrity, Coding, Billing, and Clinical departments to ensure clean claim generation.
Support coding accuracy through collaboration with revenue integrity.
Coordinate with IT on encoder, EHR, Utilization Management and Clinical Denials & Appeals system optimization.
Education & Training
Provide regular Utilization Management and Clinical Denials & Appeals education on clinical denials updates, documentation changes, and audit findings.
Mentor Utilization Review/Clinical Denials & Appeals specialists to support career growth and development.
Coordinating with Healthcare Providers:
Work closely with physicians, nurses, and other healthcare professionals to ensure timely and accurate documentation that reflects the care provided to patients. Obtain clarification as appropriate.
Other duties and responsibilities as assigned.
QUALIFICATIONS:
Required Qualifications:
Supervisory Experience: At least 1 year of utilization management and/or clinical denials and appeals supervisory experience.
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:
Proven leadership experience managing teams, including coaching, mentoring, and performance management.
Ability to independently lead teams, set project direction, develop key deliverables, escalate risks, and influence stakeholders.
Strong analytical and critical thinking skills.
Experience in a matrixed environment
Excellent written and verbal communication skills; ability to create impactful presentations
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