Supervisor Clinical Denials Utilization Management

Guidehouse•Huntsville, AL

1d•$77,000 - $129,000

About The Position

Nurse Supervisor will be in charge of overseeing the Clinical Denials UM Department under the direction Supervision of the Manager/Director. The Nurse Supervisor will maintain strong client relationships and attend meetings as needed. They will assist with SME questions and End of Month reporting as needed. Nurse Supervisor will work with in production as utilization metrics call for such. Clinical Review & Medical Necessity Conducts comprehensive medical necessity reviews using evidence‑based guidelines (Milliman or InterQual) Performs initial, concurrent, and retrospective reviews to ensure accuracy and completeness of documentation supporting medical necessity. Care Coordination & Collaboration Partners with care managers, social workers, pharmacists, and multidisciplinary care teams to support progression‑of‑care objectives. Documentation, Compliance & Quality Ensures thorough, timely, and accurate documentation in accordance with regulatory, payer, and organizational standards. Adheres to utilization management performance metrics, including call volume, case reviews, and turnaround times. Applies strong critical‑thinking skills to evaluate complex clinical scenarios and synthesize multiple data sources into sound decisions. Technical & Professional Competencies Utilizes multiple systems, Microsoft Office applications, and clinical tools Maintains objectivity and consistency in decision‑making, leveraging clinical facts and established guidelines. Demonstrates knowledge of reimbursement methodologies, payer regulations, and managed care trends.

Requirements

University Degree (Relevant experience may be substituted for formal education or advanced degree)
5+ years Utilization Review experience
Current Registered Nursing License
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form

Nice To Haves

Behavioral Health Experience
Medical Terminology
Bachelor's degree in Nursing

Responsibilities

Overseeing the Clinical Denials UM Department under the direction Supervision of the Manager/Director.
Maintain strong client relationships and attend meetings as needed.
Assist with SME questions and End of Month reporting as needed.
Work with in production as utilization metrics call for such.
Conducts comprehensive medical necessity reviews using evidence‑based guidelines (Milliman or InterQual)
Performs initial, concurrent, and retrospective reviews to ensure accuracy and completeness of documentation supporting medical necessity.
Partners with care managers, social workers, pharmacists, and multidisciplinary care teams to support progression‑of‑care objectives.
Ensures thorough, timely, and accurate documentation in accordance with regulatory, payer, and organizational standards.
Adheres to utilization management performance metrics, including call volume, case reviews, and turnaround times.
Applies strong critical‑thinking skills to evaluate complex clinical scenarios and synthesize multiple data sources into sound decisions.
Utilizes multiple systems, Microsoft Office applications, and clinical tools
Maintains objectivity and consistency in decision‑making, leveraging clinical facts and established guidelines.
Demonstrates knowledge of reimbursement methodologies, payer regulations, and managed care trends.

Benefits

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
Position may be eligible for a discretionary variable incentive bonus
Parental Leave
401(k) Retirement Plan
Basic Life & Supplemental Life
Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
Short-Term & Long-Term Disability
Tuition Reimbursement, Personal Development & Learning Opportunities
Skills Development & Certifications
Employee Referral Program
Corporate Sponsored Events & Community Outreach
Emergency Back-Up Childcare Program