Senior Manager, Utilization Review & Denials

St. John's Riverside Hospital • City of Yonkers, NY

5d

About The Position

John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.
St. John’s has been an integral part of the community since the 1890's and its’ commitment to provide the community with the most advanced medical services available continues to be the hospitals’ vision, mission and value. St. John's Riverside Hospital built itself around an early foundation of nursing and community service. In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul. St. John’s dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.
St. John’s Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. John's Riverside Hospital to their care.
St. John’s Riverside Hospital is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.
Personalized care together with advanced technology is what it means to be Community Strong
The Senior Manager of Utilization Review & Denials provides leadership and oversight for the hospital’s Utilization Review (UR) and denial prevention program to ensure appropriate utilization of healthcare services, regulatory compliance, and optimal reimbursement. This role oversees medical necessity reviews, admission status determinations, and denial management processes while collaborating with clinical, care management, and revenue cycle teams.
The Senior Manager leads strategies to reduce payer denials, improve documentation supporting medical necessity, and ensure adherence to CMS regulations, payer guidelines, and evidence-based criteria.

Requirements

• 5+ years of clinical, case management, or utilization review experience
• 3+ years of leadership or supervisory experience
• Experience managing medical necessity denials and payer appeals
• Strong knowledge of CMS regulations, Medicare guidelines, and payer policies
• Experience with InterQual or MCG criteria
• Bachelor’s degree in Nursing, Health Administration, or related healthcare field required

Nice To Haves

• Master’s degree preferred
• Current RN license preferred
• Certification such as ACM, CCM, or CPUR preferred

Responsibilities

• The Senior Manager of Utilization Review & Denials provides leadership and oversight for the hospital’s Utilization Review (UR) and denial prevention program to ensure appropriate utilization of healthcare services, regulatory compliance, and optimal reimbursement.
• This role oversees medical necessity reviews, admission status determinations, and denial management processes while collaborating with clinical, care management, and revenue cycle teams.
• The Senior Manager leads strategies to reduce payer denials, improve documentation supporting medical necessity, and ensure adherence to CMS regulations, payer guidelines, and evidence-based criteria.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 501-1,000 employees