Utilization Denials Supervisor - FT - Day - Utilization Resource Management Trenton NJ

Capital Health (US)

2d•$94,141 - $122,990•Onsite

About The Position

The Utilization Denials Supervisor manages inpatient denials and concurrent monitoring workflows to promote clinical competence, financial accuracy and cost-effective patient outcomes. This position directs assigned staff, establishing protocols to plan, review and evaluate daily denial tracking operations. The Utilization Denials Supervisor also audits denied encounters throughout the appeals lifecycle to ensure timely responses, identify payer trends and maximize revenue recovery. Additionally, the position maintains relationships with clinical teams and external insurance payers while leading departmental performance improvement and quality monitoring initiatives.

Requirements

Bachelor of Science in Nursing (BSN) or a Bachelor’s degree in a related healthcare field.
Five years of experience in nursing and three years of experience in case management, including utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination.
Inpatient denial appeal experience required.
Registered Nurse - NJ
Comprehensive knowledge of commercial insurance and government payer guidelines.
Demonstrated familiarity with evidence-based medical necessity criteria platforms, such as InterQual or MCG.
Working knowledge of clinical quality auditing and Inter-Rater Reliability (IRR) methodology.
Proven understanding of CMS conditions of participation, Joint Commission standards and federal appeal timeline regulations.
Advanced operational familiarity with utilization review platforms and clinical EMR software.
Working understanding of the healthcare revenue cycle and formal appeal documentation workflows.
Professional proficiency with the full Microsoft Office suite of applications.
Demonstrated data management capabilities to track and report department-specific denial metrics.
Natural ability to interpret multi-format instructions, including written text, data graph and process diagrams.
Strong analytical and critical thinking skills to resolve complex billing and medical necessity disputes.
Advanced interpersonal and negotiation skills, with the ability to communicate clearly in both verbal and written formats.
Proven capacity to effectively manage multiple projects simultaneously and pivot quickly in a fast-paced environment.
Demonstrated ability to lead and elevate small teams.

Responsibilities

Oversee the end-to-end inpatient concurrent denial lifecycle process for the department
Support the immediate denial and appeal process by driving timely, accurate and efficient responses for all medical necessity rejections
Partner with Patient Access, Health Information Management (HIM) and Revenue Integrity to coordinate clinical components and secure appropriate reimbursement
Collaborate with leadership across the utilization review division to solve operational problems and develop cross-functional solutions
Maintain and organize staff workflows to ensure concurrent denials are managed according to departmental policies
Coordinate appropriate staffing schedules to maintain operational commitments and support employee satisfaction
Monitor staff turnaround times to track individual productivity and drive progress toward departmental performance goals
Assess educational needs and provide targeted training, mentoring and onboarding for utilization denials staff
Conduct formal employee performance appraisals, manage the reward and discipline process and resolve internal staff issues
Perform daily inpatient concurrent denials management functions when needed to support operational volume
Perform precise chart and utilization review audits to measure team performance and ensure clinical alignment
Proactively identify denial prevention opportunities and structural trends to provide education that reduces avoidable insurance rejections
Identify and share emerging trend data related to case status compliance, medical necessity criteria and payer behavior
Support the hospital’s Utilization Committee through the targeted analysis and presentation of clinical outcomes data
Monitor the inpatient utilization process to ensure full alignment with applicable healthcare standards, federal regulations and payer contracts
Maintain current, actionable knowledge of relevant CMS, NJDHSS, DOBI and QIO regulations related to managed care and utilization
Prepare for and maintain accurate documentation of external utilization audits conducted by commercial payers and the QIO
Participate actively in DNV accreditation surveys and other mandatory regulatory readiness or preparation activities
Perform other duties as assigned