Vaughan Regional Medical Center/ScionHealth is looking for a Utilization Management Manager to serve as the operational driver for timely and effective denial management. This non-clinical role executes processes to protect revenue and keep patient care moving forward by monitoring concurrent review processes, tracking denial activity, and coordinating with multiple teams.
What You'll Do
- Serve as a key team member and subject matter expert on denial prevention and coordination within the Central Access and Authorizations Team (CAAT).
- Work with facility to gather clinical information from medical records, which may include printing and scanning into required systems.
- Ensure all denial-related documentation is complete, accurate, and submitted within required timeframes.
- Collaborate with other members of the CAAT, Business Development, Case Management, and Clinical Teams in the denial management process.
- Coordinate and schedule peer-to-peer physician consults as needed.
- Monitor and track insurance denials to identify trends in the data.
- Communicate authorization outcomes to appropriate personnel (hospital and Centralized Business Office).
- Manage denial root cause analysis efforts, including capturing lessons learned, identifying training opportunities, and providing follow-up.
- Monitor concurrent review processes for continued stay authorizations to identify potential denial risks.
- Compile data for analysis of trends and opportunities by hospital, payer, or Region.
- Monitor and track total certified days for managed payers and communicate missing certifications to hospital personnel.
- Identify trends and opportunities with specific facilities, payors, and staff members related to the concurrent review process and denials.
- Compile and communicate reports for facility and leaders on denial trends for continuous improvement opportunities.
- Support ongoing analytics and data reporting requirements.
- Maintain a working knowledge of government and non-government payor practices, regulations, standards, and reimbursement.
- Maintain clinical knowledge to support the utilization management team.
- Participate in continuing education/professional development activities.
- Learn and develop full knowledge of the CAAT Admission Processes and actively seek to continuously improve them.
- Learn and have a full understanding of scheduling and pre-register routines in Meditech and any other referral platform utilized by the CAAT team.
- Perform ad hoc duties as assigned that fall within the scope of the CAAT team.
What We're Looking For
- A team player, able to communicate and demonstrate a professional image and attitude.
- Excellent oral and written communication and interpersonal skills.
- Strong computer skills with both standard and proprietary applications.
- Data entry with attention to detail.
- Ability to conduct job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.
- Communicates and demonstrates a professional image/attitude for patients, families, clients, coworkers and others.
- Adherence to policies and practices of ScionHealth.
- Must read, write, and speak fluent English.
- Must have good and regular attendance.
- This role reports to a building; you may cover more than one building depending on market alignment and structure.
Technical Stack
- Meditech
- Referral Manager
Team & Environment
You will be a key team member of the Central Access and Authorizations Team (CAAT), collaborating with Business Development, Case Management, and Clinical Teams.
Work Mode
This is an onsite position located in Green Cove Springs, FL.
Vaughan Regional Medical Center/ScionHealth is an equal opportunity employer.
