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 o…
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 o…
Skills: Clinical Appeals Writing, Medical Necessity Review, Denials Management, InterQual, MCG Guidelines
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$80k–$105k/yr
Full-time
associate degree, bachelor degree
Medical Insurance, Dental Insurance, Vision Insurance, Wellness Programs, 401(k) Plan, Employer Match
Posted 36d ago
~40 hrs/week
Remote in Chicago, Illinois, United States
Responsibilities
Responsible for the production and quality functions of a Utilization and Denials Management team, ensuring client goals and accuracy are met. This includes performing QA audits, providing staff coaching, and collaborating with stakeholders to streamline operational workflows.
Requirements
Requires a Registered Nurse license with an Associate Degree in Nursing and 3-5 years of acute care clinical experience. Candidates must have at least one year of QA experience in utilization management or clinical appeals and proficiency in InterQual or MCG guidelines.
Full job description
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.
The Utilization and Denials Management Auditor is responsible for the day-to-day production and quality functions of a team of Utilization and Denials Management specialists specializing in meeting client production goals and accuracy goals. The Auditor assists Utilization and Denials management in preparing daily operational reports, provide QA (quality assurance) feedback, and participate in the client interactions and internal stakeholder meetings.
KEY RESPONSIBILITES:
Quality Assurance (QA) & Delivery
Assists in QA program build, including advising on the most critical aspects of the workflow/accounts to audit, attributes of an effective audit program, and how to leverage automation/efficiency tools
Monitors performance of all Utilization and Denials Management staff using key metrics including, but not limited to Utilization Management and Clinical Denials & Appeals productivity and accuracy performance.
Escalate Production and QA concerns or roadblocks to the Manager for involvement as needed. Work closely with the Training teams members to communicate progress across the Team to the Manager.
Demonstrates domain expertise in quality process related to meeting production schedules and the documentation of medical diagnoses and treatment practices
Deep understanding of both the production and quality assurance Utilization and Denials Management process and guidelines.
QA Administration & Documentation
Experience providing training, coaching, and development to team members, as well as providing regular feedback regarding work performance
Monitors and maintains team QA records and auditing/education findings for Utilization and Denials Management staff.
Completes any special projects, such as full Utilization and Denials Management audit, and other duties as assigned in a timely manner.
Mentors staff to maximize performance and potential.
Assist in maintaining and monitoring team members' job satisfaction and morale.
Performance & Evaluation
Reviews both production and quality accuracy reporting and/or system reports on progress for all assigned projects and share feedback
Motivates team members through effective training and coaching to improve quality and professionalism on work assignments. Conducts monthly team meetings and annual performance evaluations with team members.
Collaboration & Stakeholder Management
Partner with global Operations, Training, and HR to streamline onboarding and on-the-job learning (OJL).
Participate in client calibration calls to align training KPIs with operational metrics.
Support client visits, internal audits, and process reviews by presenting training dashboards and achievements.
Other duties and responsibilities as assigned.
QUALIFICATIONS:
Required Qualifications:
QA Experience: At least 1 year of Utilization management and/or Clinical appeals writing QA or auditing experience in healthcare setting.
Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience.
Education: Associate Degree in Nursing (ADN) or Diploma in Nursing.
Licensure: Must be Registered Nurse and with active USRN license.
RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
Preferred Qualifications:
Education: Science in Nursing (BSN) preferred
Credential/Certification:Case management or clinical appeals or clinical denials certification (ACMA) is preferred.
Software Knowledge: Proficiency with using computer programs for tracking authorization, and/or denials and appeals . Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)
Additional Job Description
The estimated base salary range for this job is $80,000 - $105,000. The range represents a good faith estimate of the range that Huron reasonably expects to pay for this job at the time of the job posting. The actual salary paid to an individual will vary based on multiple factors, including but not limited to specific skills or certifications, years of experience, market changes, and required travel. The job is also eligible to participate in Huron’s benefit plans which include medical, dental and vision coverage and other wellness programs. The salary range information provided is in accordance with applicable state and local laws regarding salary transparency that are currently in effect and may be implemented in the future.
Huron is a global professional services firm that collaborates with organizations to solve complex challenges and achieve ambitious goals. We help clients improve performance, accelerate transformation, and unlock new opportunities for growth through deep industry expertise, innovative thinking, and practical execution. By embracing diverse perspectives, encouraging new ideas, and challenging the status quo, we create sustainable results that empower organizations and their people to own the future.
Learn more at huronconsultinggroup.com.
Offices: 550 W. Van Buren Street, Chicago, IL 60607, US · 225 Franklin St, Suite 2010, Boston, Massachusetts 02110, US · 265 Franklin St, Suite 402, Boston, Massachusetts 02110, US · 3950 River Ridge Dr NE, Suite A, Cedar Rapids, Iowa 52402, US · 375 N Front St, Suite 125, Columbus, Ohio 43215, US
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