Utilization Review Clinical Manager - Denials (Registered Nurse)

Job Description

Job Description

Job Description : Manager of Clinical Utilization Management - Denial Compliance

Location : Burbank, CA

Position Type : Hybrid (85% remote, 15% onsite in Northridge, CA); Full-Time Salaried Position

Company : Vivo HealthStaff Inc.

Overview :

Vivo HealthStaff is recruiting for a dedicated Manager of Clinical Utilization Management - Denial Compliance. This role is pivotal in ensuring a streamlined and compliant denial process, in line with regulatory, accreditation, and health plan standards.

Key Responsibilities :

1. Oversee both licensed and non-licensed denial unit staff, managing daily tasks, performance reviews, and any necessary disciplinary actions.

2. Foster effective communication and collaboration with physician reviewers, medical directors, and other relevant departments.

3. Ensure timely responses to requests and maintain high standards of compliance and privacy.

4. Assist in the preparation of various reports, including departmental work-plans and audits.

5. Monitor and enhance the quality of the denial process internally.

6. Design and deliver training sessions for the denial unit staff to ensure top-notch, compliant communication.

7. Stay updated with state and federal regulations related to the department and implement necessary changes.

8. Lead the department towards achieving set objectives and provide guidance to team members.

9. Implement procedures to ensure alignment with company policies and influence process improvements.

10. Handle other duties as directed by the management.

Qualifications :

1. Graduate from an accredited Registered Nursing Program; RN preferred.

2. Minimum of five years in prior-authorization, appeals & grievance, or health plan compliance.

3. Proven experience in project development, staff supervision, and performance monitoring.

4. Strong communication skills, both verbal and written.

5. Ability to manage multiple projects in a high-stress environment and adapt to changing priorities.

6. Proficiency in MS Office and a computerized environment.

7. Valid CA driver's license and car insurance.

Policies :

1. Uphold honesty and integrity.

2. Adhere to privacy, compliance policies, and the corporate code of conduct.

3. Lead and participate in team meetings and promote organizational goals.

4. Provide top-tier customer service and be adaptable to flexible work hours.

Benefits :

• Comprehensive healthcare coverage.
• Competitive 401k plan.

Vivo HealthStaff is a healthcare staffing and recruitment firm based in the San Francisco Bay Area, providing permanent and temporary opportunities to organizations across the United States.