<p>SUMMARY:</p> <p>We are currently seeking a Utilization Management Analyst to join our Denials Analysis. This full-time role will primarily work remotely, but may need to come on-site when needed (Day).</p> <p>Purpose of this position: The Utilization Management Analyst plays a critical role in reviewing, appealing, and preventing clinical denials related to medical necessity, level-of-care, and authorization issues. This position bridges clinical</p> <p>and revenue cycle operations by evaluating payer denials, coordinating peer-to-peer reviews, and working</p> <p>closely with physician advisors, case management, and revenue cycle teams. The UM Analyst helps</p> <p>ensure regulatory compliance, timely appeals, and reduction of avoidable denials through proactive</p> <p>collaboration and data-driven insight.</p> <p>Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Colorado Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Nevada, North Carolina, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin.</p> <p>RESPONSIBILITIES:</p> <ul> <li>Create and keep-current a Payer Grid to track authorization rules, contacts, and changes supporting a denials prevention program </li><li>Collaborate with UM staff to review for medical necessity and authorization-related denials to determine appeal potential based on clinical documentation, payer policies, and CMS criteria </li><li>Collaborate with UM staff to draft and submit compelling clinical appeals, including summaries and supporting documentation in accordance with payer-specific requirements </li><li>Coordinate peer-to-peer reviews and communicate with physicians, case management, and payers to ensure timely escalation and resolution </li><li>Collaborate with Care Management, Clinical Documentation Improvement (CDI), and Revenue Integrity teams to identify and close documentation gaps </li><li>Monitor and manage assigned work queues in Epic for UM-related denials, ensuring timely follow-up and resolution </li><li>Evaluate denied inpatient claims for appropriate level-of-care assignment using InterQual, MCG, or similar criteria </li><li>Participate in multidisciplinary denial review or task force meetings to identify trends and root causes </li><li>Provide feedback and education to clinical and non-clinical staff to reduce preventable denials and improve documentation quality </li><li>Support proactive denial prevention by reviewing high-risk accounts and participating in concurrent review processes </li><li>Track appeal success rates and denial overturn metrics; report findings to leadership to inform strategy </li></ul> <p>QUALIFICATIONS:</p> <p>Minimum Qualifications:</p> <ul> <li>Associate degree in Health Care related field, Health Information Management, or related field </li><li>Minimum 3 years of experience in clinical care, utilization review, case management, or clinical denials/appeals </li><li>OR- </li><li>An approved equivalent combination of education and experience </li></ul> <p>Preferred Qualifications:</p> <ul> <li>Bachelor's degree </li><li>Active RHIA, RHIT, CCS, or similar clinical/technical licensure </li><li>Experience with payer guidelines, authorization workflows, and appeal writing </li></ul> <p>Knowledge/ Skills/ Abilities:</p> <ul> <li>Strong understanding of payer denial policies, CMS guidelines, and UM criteria (InterQual, MCG, etc.) </li><li>Proficient in interpreting medical records, clinical terminology, and reimbursement methodologies </li><li>Working knowledge of Epic </li><li>Excellent written and verbal communication skills, with the ability to interface with physicians, nurses, and payer representatives </li><li>Strong analytical skills and ability to identify trends and improvement opportunities </li></ul>