Manager, Utilization Management

The Opportunity

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.

Join our team as the expert you are now and create your future.

Position Summary

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.

Munson Healthcare revenue cycle operations are jointly operated by Huron and Munson Healthcare. Huron provides strategic revenue cycle operations leaders (managers and above are employed by Huron), while revenue cycle associates and supervisors are badged and employed by Munson Healthcare. Munson Healthcare, like all other providers in the market, is under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Munson, in collaboration with Huron, must empower leaders, clinicians, employees, affiliates, and communities to build a culture that fosters innovation to achieve the best outcomes for patients and succeed long-term.

Learn more about Munson Healthcare here: https://www.munsonhealthcare.org/.

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

Join our team as the expert you are now and create your future.

Qualifications

The Utilization Management Specialist is responsible for ensuring the appropriate utilization of healthcare services by reviewing patient cases for medical necessity, appropriateness, and efficiency of Munson Healthcare's services. This role involves collaborating with Munson Healthcare's providers, patients, and insurance companies to facilitate optimal patient outcomes while managing healthcare costs. The Utilization Management Specialist ensures compliance with regulatory requirements and organizational policies.

Key Responsibilities:

• Manage the process of conducting pre-authorization, concurrent, and retrospective reviews of healthcare services for medical necessity and appropriateness
• Evaluate clinical information to determine the necessity of hospital admissions, treatments, and procedures based on established criteria and guidelines.
• Maintain accurate and detailed records of review decisions and interactions in the utilization management system.
• Generate and analyze reports on utilization trends, denials, and appeals to identify areas for improvement.
• Ensure compliance with federal, state, and local regulations, as well as accreditation standards.
• Participate in quality assurance activities to improve utilization management processes and patient care outcomes.
• Lead UM Denials Team Meetings to address denial management strategies.
• Manage Budgeting and Staffing to ensure adequate resources and efficient operations.
• Engage in Strategic Planning with Physician Advisors and PCM Leadership for long-term goals.
• Conduct Outreach to Functional Leaders to ensure alignment and support for denial prevention initiatives.
• Conduct Long Length o