Senior Manager, Utilization Review & Denials Management

Socket.dev; Gainesville (FL); On-site; USD 110,000 - 150,000; Full time

Job summary

Socket.dev in Gainesville, FL is seeking a Manager of Utilization Review to lead utilization management across the health system, ensuring clinical appropriateness of patient status determinations, regulatory compliance, and efficient use of resources.

The role directs a team of Utilization Review Specialists and nurses, partnering with physician advisors, case management, revenue cycle, compliance, and payer relations to standardize UM processes and improve outcomes.

Qualifications

• RN license is required and active.
• Minimum five years in Utilization Management or related areas.
• Minimum three years of leadership in UM operations.
• Experience with Medicare/Medicaid and payers.
• Epic experience is required to manage workflows.

Responsibilities

• Provide operational leadership for utilization review activities.
• Establish standardized UM processes across facilities.
• Drive performance improvement and denial prevention strategies.
• Collaborate with physician advisors, case management, revenue cycle, and payer relations.
• Oversee inpatient, observation, and outpatient status determinations.

Skills

Leadership

Utilization management

Regulatory compliance

Healthcare payer relationships

Project management

Education

Bachelor’s degree in nursing

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

Tools

Epic

Job description

Socket.dev in Gainesville, FL is seeking a Manager of Utilization Review to lead utilization management across the health system, ensuring clinical appropriateness of patient status determinations, regulatory compliance, and efficient use of resources.

The role directs a team of Utilization Review Specialists and nurses, partnering with physician advisors, case management, revenue cycle, compliance, and payer relations to standardize UM processes and improve outcomes.