UM Clinical Denial Manager @ Sutter Health

We are so glad you are interested in joining Sutter Health!

Organization:

SHSO-Sutter Health System Office-Valley

Position Overview:

Manages the operations of the centralized Utilization review department for Sutter Health entities in accordance with current federal and state regulations and guidelines. Has frequent contact with hospital leadership, Nurse Executives and Directors, Risk Management & Ethics staff, Ancillary Services, Revenue Cycle and Finance Department leaders, Medical Directors, Medical Staff leaders, physicians, contracted providers, community resources post-acute agencies, patients and their families.

Job Description:

EDUCATION:

* Graduate of an accredited school of nursing

CERTIFICATION & LICENSURE:
* RN-Registered Nurse of California Upon Hire

TYPICAL EXPERIENCE:

* 8 years of recent relevant experience.

* 2 years experience in Utilization Management (UM) and Clinical Denial Management Preferred

SKILLS AND KNOWLEDGE:
* Knowledge of ACMA, CMSA, and NASW Standards of Practice.

* Knowledge of available health care and community resources

* A broad knowledge base of health care delivery and case management within a managed care environment.

* Comprehensive knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC.

* Verbal and written communication skills.

* Group presentation design and facilitation skills.

* Demonstrated ability to develop and manage complex projects.

* Working knowledge of InterQual criteria.

* Working knowledge of MIDAS and experience with an E.H.R. (EPIC preferred)

* Ability to promote teamwork and to effectively function in teams, both as a leader and as a team member.

* Ability to interact effectively with key internal and external constituents using collaboration, negotiation and analytical problem resolution skills.

* Effective human relations and interpersonal skills necessary to lead the efforts of diverse health professionals to meet program objectives.

* Ability to work effectively in a fast paced environment, directing services at multiple locations.

* Analytical and mathematical skills.

* Demonstrated ability to implement continuous quality improvement processes and techniques, including benchmarking and outcomes measurements.

* PC skills, word processing, spreadsheets and managed care software programs.

* Adheres to Sutter health policies and procedures and supports Sutter health philosophies and initiatives. Participates as member of the utilization

* Management committee (UMC).

* Strong problem resolution abilities and customer relation skills

Job Shift:

Days

Schedule:

Full Time

Days of the Week:

Monday - Friday

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

Position Status:

Exempt

Weekly Hours:

Employee Status:

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $83.00 to $132.80 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

UM Clinical Denial Manager

Sutter Health

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