Clinical Resource Management Manager Utilization, Denials and Appeals
5 days left
- Full Time
GENERAL SUMMARY Working under the direction of the Vice President, Clinical Resource Management and Chief Financial Officer, the Clinical Resource Management (CRM) Utilization, Denials and Appeals provides leadership for the case management team and oversees the Department's daily activities. Coordinates the department's utilization functions to provide efficient and effective outcome based patient centered care. Primary responsibilities include, but are not limited to, managing the denials and appeals process; assigning utilization management (UM) duties to staff members based on ratios/volumes, skills and departmental needs; identifying and mitigating problems as they occur, and addressing performance issues; coordinating with internal staff and outside vendors to address management of denials. MINIMUM REQUIREMENTS EDUCATION: Associate degree in Nursing is required, with a Bachelor's degree in Nursing or another field. Master's Degree in Healthcare Administration, Business, or Nursing is preferred. PRIOR EXPERIENCE : Minimum of 3 years' experience in Case Management and/or utilization review experience. Prior experience in management or administrative position preferred. Knowledge of payer requirements, discharge planning regulations, accreditation standards, data collection, analysis and data presentation. Knowledge of MCG, Allscripts and information systems. CERTIFICATION/REGISTRATION/LICENSURE : Licensure as a Registered Nurse in the District of Columbia is required. Certification in Case Management is preferred.