Manager Medical Necessity Review & Appeals - Patient Accounting - Full Time Exempt - Days - 8hr

Emanate Health • Covina, CA • 12h ago

Current Emanate Health Employees - Please log into your Workday account to apply

Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals.

On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country.

Job Summary

The Manager, Medical Necessity Review & Appeals is responsible for overseeing the evaluation of medical necessity, appropriateness, and cost-effectiveness of healthcare services, as well as managing the appeals process for denied claims. This role ensures compliance with federal, state, and payer regulations while implementing strategies that improve approval rates, reduce denials, and support optimal patient care. The Manager collaborates with clinical and operational leaders, and drives process improvements to enhance quality and financial performance.

Job Requirements

Minimum Education Requirement :

Completion of approved vocational nursing program. Bachelor's degree in Nursing (BSN) preferred.

Minimum Experience Requirement :

Minimum of two (2) years of recent acute clinical experience and/or two years in Case Management, Utilization Review, payer appeals or related programs required. Experience with medical necessity reviews, utilization management, and/or managed care or commercial payers is preferred. Strong communication, organizational, decision-making, and prioritization skills, self-motivated and results-oriented. Able to work professionally with physicians, nurses, staff, external agencies, and patients delivering excellent customer service. Proficient in EMR systems (e.g., Meditech) and utilization review software (InterQual, MCG). Skilled in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) for data analysis, reporting, and presentations. Ability to extract, analyze, and interpret large datasets for operational decision-making. Experienced in preparing structured reports for regulatory agencies, payers, and internal departments.

Minimum License Requirement :

California RN or LVN license. RN license is preferred.

Delivering world-class health care one patient at a time.

Pay Range:

$45.75 - $67.26

We are more than just a health system. At Emanate Health, we are a catalyst for change and a beacon for healthier lives.

When you come to any one of our locations (https://www.emanatehealth.org/locations/) , you'll be treated like family. And as part of our family, you can rest easy knowing we'll do whatever it takes to benefit your health and wellness.

Our mission

Emanate Health exists to help people keep well in body, mind and spirit by providing quality health care services in a safe, compassionate environment.

Our vision

We are an integral partner in elevating our communities' health.

Our values

Patients and their families are the reason we are here. We want them to experience excellence in all we do through the quality of our services, our teamwork, and our commitment to a caring, safe and compassionate environment.

Respect. We affirm the rights, dignity, individuality and worth of each person we serve and of each other.

Excellence. We maintain an unrelenting drive for excellence, quality and safety, and strive to continually improve all that we do.

Compassion. We care for each person and each team member as part of our family.

Integrity. We believe in fairness and honesty and are guided by our code of ethics.

Stewardship. We wisely care for the human, physical and financial resources entrusted to us.

Emanate Health is an Equal Opportunity Employer and does not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the Human Resources Department by calling 626-858-8515.

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