Utilization Denials Supervisor - FT - Day - Utilization Resource Management Trenton NJ

Utilization Denials Supervisor

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

$94,140.80 - $122,990.40

Scheduled Weekly Hours: 40

Position Overview

The Utilization Denials Supervisor manages inpatient denials and concurrent monitoring workflows to promote clinical competence, financial accuracy and cost-effective patient outcomes. This position directs assigned staff, establishing protocols to plan, review and evaluate daily denial tracking operations. The Utilization Denials Supervisor also audits denied encounters throughout the appeals lifecycle to ensure timely responses, identify payer trends and maximize revenue recovery. Additionally, the position maintains relationships with clinical teams and external insurance payers while leading departmental performance improvement and quality monitoring initiatives.

Minimum Requirements

Education: Bachelor of Science in Nursing (BSN) or a Bachelor's degree in a related healthcare field.

Experience: Five years of experience in nursing and three years of experience in case management, including utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination. Inpatient denial appeal experience required.

Other Credentials: Registered Nurse - NJ

Knowledge and Skills: Comprehensive knowledge of commercial insurance and government payer guidelines. Demonstrated familiarity with evidence-based medical necessity criteria platforms, such as InterQual or MCG. Working knowledge of clinical quality auditing and Inter-Rater Reliability (IRR) methodology. Proven understanding of CMS conditions of participation, Joint Commission standards and federal appeal timeline regulations. Advanced operational familiarity with utilization review platforms and clinical EMR software. Working understanding of the healthcare revenue cycle and formal appeal documentation workflows. Professional proficiency with the full Microsoft Office suite of applications. Demonstrated data management capabilities to track and report department-specific denial metrics.

Special Training: Mental, Behavioral and Emotional Abilities: Natural ability to interpret multi-format instructions, including written text, data graph and process diagrams. Strong analytical and critical thinking skills to resolve complex billing and medical necessity disputes. Advanced interpersonal and negotiation skills, with the ability to communicate clearly in both verbal and written formats. Proven capacity to effectively manage multiple projects simultaneously and pivot quickly in a fast-paced environment. Demonstrated ability to lead and elevate small teams.

Usual Work Day: 8 Hours

Reporting Relationships: Does this position formally supervise employees? Yes

Essential Functions

Oversee the end-to-end inpatient concurrent denial lifecycle process for the department

Support the immediate denial and appeal process by driving timely, accurate and efficient responses for all medical necessity rejections

Partner with Patient Access, Health Information Management (HIM) and Revenue Integrity to coordinate clinical components and secure appropriate reimbursement

Collaborate with leadership across the utilization review division to solve operational problems and develop cross-functional solutions

Maintain and organize staff workflows to ensure concurrent denials are managed according to departmental policies

Coordinate appropriate staffing schedules to maintain operational commitments and support employee satisfaction

Monitor staff turnaround times to track individual productivity and drive progress toward departmental performance goals

Assess educational needs and provide targeted training, mentoring and onboarding for utilization denials staff

Perform daily inpatient concurrent denials management functions when needed to support operational volume

Perform precise chart and utilization review audits to measure team performance and ensure clinical alignment

Proactively identify denial prevention opportunities and structural trends to provide education that reduces avoidable insurance rejections

Identify and share emerging trend data related to case status compliance, medical necessity criteria and payer behavior

Support the hospital's Utilization Committee through the targeted analysis and presentation of clinical outcomes data

Monitor the inpatient utilization process to ensure full alignment with applicable healthcare standards, federal regulations and payer contracts

Maintain current, actionable knowledge of relevant CMS, NJDHSS, DOBI and QIO regulations related to managed care and utilization

Prepare for and maintain accurate documentation of external utilization audits conducted by commercial payers and the QIO

Participate actively in DNV accreditation surveys and other mandatory regulatory readiness or preparation activities

Perform other duties as assigned

Physical Demands and Work Environment

Frequent physical demands include: Sitting, Standing, Keyboard use/repetitive motion

Occasional physical demands include: Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Twisting, Bending, Reaching forward, Reaching overhead, Squat/kneel/crawl, Wrist position deviation, Pinching/fine motor activities

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens, Chemical, Airborne Communicable Disease

This position is eligible for the following benefits:

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits Long Term Disability (LTD)
• Disability Benefits Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse
• Voluntary Life Employee
• Voluntary Life Child
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level.

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.