Utilization Management Assistant

Guidehouse•Albany, NY

5d•Onsite

About The Position

This role involves managing denied hospital claims, conducting root cause analysis, and coordinating with various teams to determine appeal viability. The assistant will assemble and submit appeal packets, track denial and appeal activity, and identify trends to support process improvement. Adherence to hospital policies, payer guidelines, and regulatory requirements is essential.

Requirements

Requires a high school diploma
3-5 years of prior relevant experience in hospital revenue cycle, clinical denials, appeals, utilization management, or medical claims processing, health information management, or a related field.

Nice To Haves

Associates or Bachelors in healthcare administration
Clinical background or experience working directly with nursing or utilization management teams.
Experience with inpatient hospital claims, DRG-based reimbursement, and payer portals.
Strong understanding of payer denial codes, appeal workflows, and hospital billing processes.
Excellent organizational, analytical, and written communication skills.
Ability to manage multiple accounts simultaneously while meeting strict deadlines

Responsibilities

Receive, triage, and prioritize denied hospital claims based on timely filing requirements, financial impact, and payer response deadlines.
Conduct root cause analysis to identify clinical, documentation, authorization, or payer-related reasons for denial.
Coordinate with nurse reviewers, coding, utilization management, and revenue cycle teams to determine appeal viability.
Assemble and submit complete appeal packets, ensuring inclusion of appropriate clinical documentation and payer-specific requirements.
Submit appeals via payer portals, secure fax, or mail, and confirm receipt to ensure timely adjudication.
Perform systematic appeal/um follow-up at defined intervals until final claim resolution is achieved.
Track denial and appeal activity, maintaining accurate documentation within hospital and payer systems.
Identify denial trends and recurring issues and communicate findings to leadership to support process improvement initiatives.
Adhere to all hospital policies, payer guidelines, and regulatory requirements related to claims and appeals processing.

Benefits

Medical, Rx, Dental & Vision Insurance
Personal and Family Sick Time & Company Paid Holidays
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