Manager, UM Denials & Payer Relations

UF Health; Gainesville (FL); On-site; USD 95,000 - 130,000; Full time

Job summary

UF Health in Gainesville seeks a UM Manager, Denials and Payer Relations to lead enterprise-wide utilization management activities, including authorization management, medical necessity compliance, denial prevention, payer escalation, and payer relationship management.

You will serve as the primary liaison across clinical operations, Revenue Cycle, and external payers, develop improvement strategies, analyze denial trends, and drive performance toward reimbursement optimization.

Qualifications

• 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 with Medicare, Medicaid, and commercial payers.
• Epic experience is a must.
• Registered Nurse (RN) required.

Responsibilities

• Provide operational leadership for enterprise-wide utilization management activities including authorization management, medical necessity compliance, and denial prevention.
• Act as primary liaison between Utilization Management, Revenue Cycle, Clinical Operations, and external payers to ensure accurate review processes.
• Develop and implement strategies to improve medical necessity compliance and decrease avoidable denials.
• Monitor payer performance and support successful appeals.
• Translate regulatory requirements into actionable operational processes.

Skills

Leadership

Data analytics

Regulatory compliance

Denials management

Payer relations

Communication

Education

Bachelor’s degree in nursing

Master’s degree in nursing, Healthcare Administration, Business Administration, or related field

Tools

Epic

Job description

Overview

The 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.

Qualifications

Education

• 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.
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