Utilization Review Lead - Denials & Compliance

Prime Healthcare Services; Lynwood (CA); On-site; USD 51,000 - 68,000; Full time

Job summary

St. Francis Medical Center is seeking an UR Supervisor to oversee utilization review and denial management, coordinating with Case Management, Business Office and Coding to streamline reporting and prevent denials.

This role requires clinical experience in acute care, plus UR/denial management expertise and strong communication. Join a team supported by Prime Healthcare in Los Angeles, with a focus on quality and patient-centered care, offering competitive compensation and comprehensive

Qualifications

• Medical, dental, physician assistant or nursing degree required.
• ECFMG certification or US-based degree in a Health and Human Services field preferred.
• Utilization Review experience highly preferred.
• Denial Management experience preferred.
• Minimum one year as a clinical documentation specialist or utilization review coordinator.
• One+ year of clinical acute care experience preferred.
• Excellent written and verbal communication skills; excellent critical thinking.

Responsibilities

• Oversee third-party payer Utilization Review and the denial management process.
• Supervise front-end to back denial management initiatives including UR, Authorization Appeals and compliance.
• Provide liaison between Case Management, Business Office and Coding to ensure timely reporting and follow-up of denials.
• Participate in regular Utilization Committee and Case Management meetings with stakeholders and corporate leadership.
• Perform audits to monitor UR and appeal/denial processes and develop process improvement plans.

Skills

Excellent written and verbal comms

Excellent critical thinking

Clinical experience

Education

Medical graduate

Dental graduate

Physician assistant

Nursing graduate

ECFMG certification or US health degree preferred

Job description

St. Francis Medical Center is seeking an UR Supervisor to oversee utilization review and denial management, coordinating with Case Management, Business Office and Coding to streamline reporting and prevent denials.

This role requires clinical experience in acute care, plus UR/denial management expertise and strong communication. Join a team supported by Prime Healthcare in Los Angeles, with a focus on quality and patient-centered care, offering competitive compensation and comprehensive