Overview
Montclair Hospital Medical Center is a 106-bed acute care, not-for-profit community hospital, received the "100 Top Hospital" in the nation award from IBM Watson Health, the Patient Safety Excellence award from Healthgrades®, and the Women's Choice Award® for America's Best Emergency Care. For more information visit Montclair-hospital.org
At Montclair Hospital Medical Center, our dedicated team of professionals are committed to our core values of quality, compassion, and community!
Why Prime Healthcare? (https://montclair-hospital.org/careers/why-healthcare-prime/) Montclair Hospital Medical Center is a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.
Our Total Rewards package includes, but is not limited to:
Paid Time Off
401K retirement plan
Outstanding Medical
Dental
Vision Coverage
Tuition Reimbursement
Many more Voluntary Benefit Options! (https://www.primehealthcare.com/careers/benefits/)
Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time.
This is a Fast-paced work environment in which you can take pride in serving an underserved community. Come Join a Team of Dedicated Healthcare Workers!!!
Montclair Hospital Medical Center is nationally recognized, locally preferred, and community focused.
Responsibilities
Utilization Review Manager is responsible for the oversight of third party payer utilization review (UR) and the denial management (DM) process. The Manager functions as an appeal/denial expert and takes an active role in managing the process and coordinating with Corporate Utilization and Authorization Appeals team. Provides supervision and direction for UR process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitate peer to-peer communication and authorization appeals process following utilization review submission to respective insurances. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Demonstrates appropriate knowledge of payer contract changes as they pertain to level of care determination and the appeal/denial process. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration/ CMO and the Utilization Review Committee wherever applicable. Participate in regular Utilization committee and Case management meetings with stakeholders from all departments and Corporate leadership team to provide necessary education and discuss progress and protocols for Insurance authorization and denial prevention strategies. Keeps abreast with the ongoing education/training to stay current with emerging industry trends on utilization review and denials management. Performs ongoing audits, to monitor UR and appeal/denial process and develops process improvement plans for identified deficiencies. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.
Qualifications
EDUCATION, EXPERIENCE, TRAINING
Medical Graduate, PA, or Nursing Graduate required.
ECFMG Certification / Bachelor's or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
Utilization Review experience preferred.
Must meet the performance standards set forth by the Hospital/ Department at UR Coordinator I position for at least 6 months.
In order to be promoted to UR Coordinator II position; the Employee must meet certain performance standards as defined by the Hospital/Department.
In order to be promoted to Corporate Case Manager position; the Employee must meet certain performance standards as defined by the Hospital/ Department and obtain the Certified Case Manager credential. 1+ year of utilization review experience is highly preferred.
1+ year of clinical experience in acute care setting preferred.
1+ year of experience with ICD-10 and CPT coding in an acute care setting preferred.
Experience with use of an encoder software product for code assignment in an acute care setting preferred.
Excellent written and verbal communication skills. Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
Ability to work independently in a time-oriented environment.
Computer literacy and familiarity with the operation of basic office equipment
Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred
Pay Transparency
Montclair Hospital Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $99,444.80 to $133,848.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
Employment Status
Full Time
Shift
Days
Equal Employment Opportunity
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC\KnowYourRights\screen\reader\10_20.pdf
Privacy Notice
Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
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FacilityMontclair Hospital Medical Center
LocationUS-CA-Montclair
ID2026-253936
CategoryManager
Position TypeFull Time
ShiftDays
Job TypeExempt
