Healthcare Utilization & Denials Leader

Billings Clinic; Billings (MT); On-site; USD 85,000 - 105,000; Full time

Job summary

Billings Clinic is seeking a Manager of Utilization Review and Denials to oversee and optimize utilization of healthcare resources across the organization. You will work with medical staff and Case Managers to assess medical necessity and lead a team of reviewers to improve efficiency and patient outcomes.

The role requires a nursing background, clinical experience, and prior supervisory experience, with a focus on regulatory compliance and collaboration with insurers to ensure timely

Qualifications

• Bachelor's Degree in Nursing required.
• Minimum 5 years of clinical experience.
• Experience with healthcare information systems and software.
• Previous management or supervisory experience.

Responsibilities

• Oversee the Utilization Review process to ensure appropriate and cost-effective use of healthcare resources.
• Develop and implement utilization management strategies and protocols in line with best practices and regulatory requirements.
• Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate medical necessity and appropriateness of treatment plans.
• Lead and mentor a team of Utilization Review Specialists, providing guidance and support in reviewing patient records and gathering clinical information.
• Analyze utilization data and trends to identify opportunities for efficiency and cost reduction.
• Monitor and assess performance of healthcare providers, implementing corrective actions as needed.
• Stay updated on regulations and technologies in utilization management and ensure compliance.
• Maintain thorough documentation of utilization review activities for regulatory and policy compliance.
• Collaborate with insurers and payers to resolve utilization-related issues and facilitate timely reimbursement.
• Participate in quality improvement initiatives with the Quality Management team to enhance patient care outcomes.

Skills

Healthcare systems

Supervisory experience

Education

Bachelor's Degree in Nursing

Job description

Billings Clinic is seeking a Manager of Utilization Review and Denials to oversee and optimize utilization of healthcare resources across the organization. You will work with medical staff and Case Managers to assess medical necessity and lead a team of reviewers to improve efficiency and patient outcomes.

The role requires a nursing background, clinical experience, and prior supervisory experience, with a focus on regulatory compliance and collaboration with insurers to ensure timely