Position Summary

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The Utilization and Appeals Manager (UAM) proactively conducts clinical reviews and appeals according to industry accepted clinical criteria guidelines. The UAM serves as interdepartmental liaison identifying denial reasons and opportunities for improvement from both internal and external sources including regulatory agencies. 

Responsibilities include but not limited to:

Receives, manages and provides clinical reviews and/or submissions as required by contractual or regulatory requirements. 

Researches initial denial, identifying reason for the denial and contributing factors that led to the denial and mitigates, manages and/or escalates denial when appropriate.

Submits all (initial and/or appeals) reviews and/or letters within contractual or regulatory timeframes.

Collaborates in clinical discussions with the Catholic Health Physician Advisor when appropriate.

Reviews results from managed ...