Utilization Review Supervisor

Prime Healthcare•Lynwood, CA

22h

About The Position

The Utilization Review Supervisor oversees third-party payer Utilization Review (UR) and denial management (DM). The role supervises and coordinates denial management initiatives from the front end through resolution, including utilization review, authorization appeals, and compliance protocols. The supervisor directs the UR process and supports analysis, resolution, monitoring, and reporting of clinical denials. The position serves as a liaison among Case Management, the Business Office, and Coding teams to support timely reporting, tracking, and follow-up of denials. The supervisor participates in Utilization Committee and Case Management meetings with departmental stakeholders and corporate leadership to provide education and discuss progress, protocols, insurance authorization, and denial-prevention strategies. The role also conducts ongoing audits of the UR and appeals/denial processes, develops improvement plans for identified deficiencies, and applies knowledge of federal, state, and intermediary guidelines for inpatient acute care and lower levels of care.

Requirements

Medical, dental, physician assistant, or nursing graduate.
At least one year of experience as a clinical documentation specialist or utilization review coordinator.
Excellent written and verbal communication skills.
Excellent critical-thinking skills.

Nice To Haves

ECFMG certification and/or a bachelor's degree or higher from a U.S.-based accredited institution in a Health and Human Services field.
Utilization Review experience.
Denial Management experience.
At least one year of clinical experience in an acute care setting.

Responsibilities

Oversee third-party payer Utilization Review and the denial management process.
Supervise and coordinate front-end through back-end denial management initiatives, including utilization review, authorization appeals, and compliance protocols.
Provide supervision and direction for the UR process, including analysis, resolution, monitoring, and reporting of clinical denials.
Liaise with Case Management, Business Office, and Coding teams to support timely reporting, tracking, and follow-up of denials.
Participate in Utilization Committee and Case Management meetings with departmental stakeholders and corporate leadership.
Provide education and discuss progress, protocols, insurance authorization, and denial-prevention strategies.
Conduct ongoing audits of the UR and appeal/denial processes and develop process-improvement plans for identified deficiencies.
Apply knowledge of federal, state, and intermediary guidelines related to inpatient acute care hospitalization and lower levels of care.
Perform other assigned duties.