Utilization & Denials Management Manager

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Position: Utilization & Denials Management Manager
Location: Taguig
Work setup & shift: Onsite | Night shift

Why join MicroSourcing
Youu0027ll have:

• Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time-off with cash conversion, group life insurance, and performance bonuses
• A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company-sponsored events and activities.
• Work-Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.
• Career Growth: Take advantage of opportunities for continuous learning and career advancement.
• Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.

Your Role
As a Utilization & Denials Management Manager, you will:

The Utilization and Denials Management Manager is responsible for the day-to-day operations and oversight of initial and concurrent clinical reviews in addition to Clinical Denials processes. This role ensures accuracy in utilization management up to and including the review of the claims denied and carry out the appeals process appropriately and in a timely manner. This leader ensures adherence to regulatory guidelines and payer requirements and supports optimal reimbursement through the appeals process.

Operational Oversight:

• Manages team to achieve specific goals by overseeing daily activities, assigning tasks, and providing guidance and motivation.
• Key responsibilities include setting objectives, ensuring efficient task completion, monitoring performance, solving problems, and facilitating communication between the team and upper management.
• Effective team managers possess strong leadership, communication, and problem-solving skills.

Quality & Compliance:

• Address Utilization management and Clinical Denials and partner with billing and A/R teams to identify root causes.
• Stay current with Utilization Management and Clinical Denials updates and disseminate guidance to staff.
• Ensure Utilization Management, Clinical Denials & Appeals policies & procedures are current and reflect the most compliant/accepted practices for medical coding.

Collaboration & Support:

• Effectively communicate teamu0027s performance in Operations Meeting including reporting on KPIs, progress, and opportunity areas.
• Work closely with HIM, Revenue Integrity, Coding, Billing, and Clinical departments to ensure clean claim generation.
• Support coding accuracy through collaboration with revenue integrity.
• Coordinate with IT on encoder, EHR, Utilization management and Clinical Denials & Appeals system optimization.

Education & Training

• Provide guidance on Utilization Management and Clinical Denials & Appeals education strategies including on clinical denials updates, documentation changes, and audit findings.
• Mentor Utilization Management/Clinical Denials & Appeals supervisors, trainers/QA specialists, or RN specialists to support succession planning and career development.

Coordinating with Healthcare Providers:

• Work closely with physicians, nurses, and other healthcare professionals to ensure timely and accurate documentation that reflects the care provided to patients. Obtain clarification as appropriate.

Other duties and responsibilities as assigned.

About the Client - Huron
Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes.

Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients.

Joining the Huron team means you'll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise.

What You Need
Non-negotiables

• Management Experience: At least 2 years of utilization management and/or clinical denials and appeals management experience.
• Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred