Manager - Utilization Review and Denials

You'll want to join Billings Clinic for our outstanding quality of care, exciting environment, interesting cases from a vast geography, advanced technology and educational opportunities. We are in the top 1% of hospitals internationally for receiving Magnet Recognition consecutively since 2006.

And you'll want to stay at Billings Clinic for the amazing teamwork, caring atmosphere, and a culture that values kindness, safety and courage. This is an incredible place to learn and grow. Billings, Montana, is a friendly, college community in the Rocky Mountains with great schools and abundant family activities. Amazing outdoor recreation is just minutes from home. Four seasons of sunshine!

You can make a difference here.

About Us

Billings Clinic is a community-owned, not-for-profit, Physician-led health system based in Billings with more than 4,700 employees, including over 550 physicians and non-physician providers. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital. Learn more about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality.

Your Benefits

We provide a comprehensive and competitive benefits package to all full- and part-time employees (minimum of 20 hours/week), including Medical, Dental, Vision, 403(b) Retirement Plan with employer matching, Defined Contribution Pension Plan, Paid Time Off, employee wellness program, and much more. Click here for more information or download the Employee Benefits Guide.

Magnet: Commitment to Nursing Excellence

Billings Clinic is proud to be recognized for nursing excellence as a Magnet-designated organization, joining only 97 other organizations worldwide that have achieved this honor four times. The re-designation process happens every four years. Click here to learn more!

Pre-Employment Requirements

All new employees must complete several pre-employment requirements prior to starting. Click here to learn more!

Manager - Utilization Review and Denials

Billings Clinic (Billings Clinic Main Campus)

req12692

Shift: Day

Employment Status: Full-Time (.75 or greater)

Hours per Pay Period: 1.00 = 80 hours every two weeks (Exempt)

Starting Wage DOE: $0.00 - 0.00

This position is responsible for overseeing and optimizing the utilization of resources, promoting efficiency and improving patient outcomes. The Manager of Utilization Review plays a crucial role in monitoring the quality of care provided, coordinating with various departments and implementing strategies to minimize costs while maintaining high standards of patient care.

Essential Job Functions

• Oversee the Utilization Review process to ensure the appropriate and cost-effective use of healthcare resources.
• Develop and implement utilization management strategies and protocols, in accordance with industry best practices and regulatory requirements.
• Collaborate with medical staff, Case Managers, and other healthcare professionals to evaluate the medical necessity and appropriateness of treatment plans.
• Lead and mentor a team of Utilization Review Specialists, providing guidance and support in reviewing patient medical records and gathering relevant clinical information.
• Analyze utilization data and trends to identify opportunities for improving efficiency and reducing unnecessary costs.
• Monitor and assess the performance of healthcare providers, identifying areas for improvement and implementing corrective action plans.
• Stay abreast of changing regulations, guidelines, and technologies in the field of healthcare utilization management, and develop strategies to ensure compliance and enhance operational efficiency.
• Maintain accurate and comprehensive documentation of all utilization review activities, ensuring compliance with organizational policies and regulatory requirements.
• Collaborate with insurance companies, government agencies, and other third-party payers to ensure timely reimbursement and resolve any utilization-related issues.
• Participate in the development and implementation of quality improvement initiatives, working collaboratively with the Quality Management team to enhance patient care outcomes.

Minimum Qualifications

Education

• 4 Year / Bachelors Degree Bachelors Degree in Nursing

Experience

• 5 years of Experience in a clinical setting
• Experience with healthcare information systems and software
• Previous management or supervisory experience

Certifications and Licenses

• Current Montana Registered Nurse License

Billings Clinic is Montana's largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more at www.billingsclinic.com/aboutus

Billings Clinic is committed to being an inclusive and welcoming employer, that strives to be kind, safe, and courageous in all we do. As an equal opportunity employer, our policies and processes are designed to achieve fair and equitable treatment of all employees and job applicants. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, religion, sex, gender identity, sexual orientation, pregnancy, marital status, national origin, age, genetic information, military status, and/or disability. To ensure we provide an accessible candidate experience for prospective employees, please let us know if you need any accommodations during the recruitment process.