The Clinical Denials and Utilization Review Supervisor provides clinical and operational oversight of utilization review and clinical denial management functions. The individual is responsible for promoting effective utilization management practices, ensuring compliance with regulatory and payer requirements, supporting clinical denial and appeal processes, and supporting appropriate patient status determination and reimbursement. The Clinical Denial & UR Supervisor also handles data analysis and reporting needs for the department and other administrative duties as required.

Working collaboratively with Care Management leadership, physician advisors, and Revenue Cycle teams, the Clinical Denials Supervisor analyzes denial trends, educates staff on documentation and follow-up practices, and implements strategies to reduce reimbursement risk and organizational write-offs. This role exercises a high degree of independent judgment in managing denial and appeal activities, communicating outcomes to key stakeholders, and supporting the organization's financial and operational objectives while upholding Care New England's mission, values, and service standards.

The Clinical Denial & Utilization Review Supervisor provides oversight of utilization review practices, including monitoring workflows, identifying opportunities for process improvement, and developing and implementing standardized procedures and staff education. They serve as a clinical resource to Care Management staff and collaborate with Physician Advisors, Medical Staff, Revenue Cycle, and other interdisciplinary stakeholders to address medical necessity, patient status, documentation, and reimbursement concerns. The Supervisor also coordinates Utilization Review Committee meetings, facilitating the review of utilization trends, performance outcomes, and opportunities for improvement. They work independently to plan, schedule and organize activities that directly impact hospital and physician reimbursement. 

• Research clinical denials related to referral, medical necessity, case management, non-covered services, resulting in denials and delays in payment.
• Collaborate with Revenue Cycle appeals team to provide clinical oversight and justification for appeal submission.
• Monitor payer trends and analyze data related to payer behavior regarding denials.
• Develop, implement, and evaluate processes to ensure accurate and timely collection of information.
• Serve as a resource for hospital case management departments regarding concurrent denials.
• Provide operational oversight of utilization review (UR) activities to ensure timely, accurate, and consistent application of established utilization management practices regulatory requirements, and organizational policies.
• Identify opportunities to improve utilization review workflows, documentation practices, and escalation processes to support regulatory compliance, operational efficiency, and appropriate reimbursement.
• Promote collaboration among Case Management, Physician Advisors, Revenue Cycle, CDI, Nursing, and Medical Staff to support effective utilization management and denial prevention.
• Analyze observation utilization metrics, including observation length of stay, extended observation stays exceeding 24 and 48 hours, patient status changes, and medical necessity denials to identify trends and opportunities for improvement.
• Serve as a clinical and operational resource for staff regarding complex utilization review cases, payer denials, medical necessity concerns, and escalation pathways.
• Work with and educate staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations and process improvements.
• Coordinate appropriate status determinations using InterQual and Medicare guidelines.
• Review payer communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalate potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
• Assist with clinical support for complex, specialized billing and follow-up workflows including but not limited to:
  • RAC correspondence and appeal processing, as well as other audit reviews,
  • advanced billing procedures requiring extensive communication with other departments, and
  • consecutive account processing and Medicare A/B split claims processing.
• Develop and maintain departmental dashboards, performance reports, and key performance indicators to monitor utilization management effectiveness, regulatory compliance, denial trends, and operational outcomes.
• Utilize data-driven insights to recommend, implement, and evaluate initiatives aimed at improving utilization review practices, reducing avoidable denials, and supporting organizational financial and quality outcomes.
• Support director in other related responsibilities as requested.
• Respond to patient and family inquiries regarding denials.
• Serve as a resource, maintain expertise and continue self-education by attending applicable conferences, workshops and interdisciplinary meetings.
• Utilize local, regional and national forums to continuously enhance expertise and knowledge base.
• Participate in applicable professional organizations and committees.
• Perform other related duties as requested.

• Bachelor's Degree Required; Field of Study: Nursing (must be graduate of an accredited nursing program).
• Minimum 3 to 5 Years of experience in hospital case management. Previous management of clinical appeals preferred.
• Rhode Island Registered Nurse licensure required.
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification required.
• Demonstrated competency in InterQual and/or MCG and Medicare rules and regulations.
• Knowledge and understanding of EMR functionality required. 
• Expertise in patient population needs, nursing practices, and department-specific competencies.
• Understanding of Department of Health regulations, accreditation standards, and compliance requirements.
• Application of quality improvement, risk management, and patient safety principles.
• Adherence to infection prevention and control policies and procedures.
• Proficiency in nursing documentation standards and regulatory requirements.
• Understanding of the Nurse Practice Act and professional nursing standards.
• Preparedness for disaster response, emergency management, and customer service excellence.

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.

• Research clinical denials related to referral, medical necessity, case management, non-covered services, resulting in denials and delays in payment.
• Collaborate with Revenue Cycle appeals team to provide clinical oversight and justification for appeal submission.
• Monitor payer trends and analyze data related to payer behavior regarding denials.
• Develop, implement, and evaluate processes to ensure accurate and timely collection of information.
• Serve as a resource for hospital case management departments regarding concurrent denials.
• Provide operational oversight of utilization review (UR) activities to ensure timely, accurate, and consistent application of established utilization management practices regulatory requirements, and organizational policies.
• Identify opportunities to improve utilization review workflows, documentation practices, and escalation processes to support regulatory compliance, operational efficiency, and appropriate reimbursement.
• Promote collaboration among Case Management, Physician Advisors, Revenue Cycle, CDI, Nursing, and Medical Staff to support effective utilization management and denial prevention.
• Analyze observation utilization metrics, including observation length of stay, extended observation stays exceeding 24 and 48 hours, patient status changes, and medical necessity denials to identify trends and opportunities for improvement.
• Serve as a clinical and operational resource for staff regarding complex utilization review cases, payer denials, medical necessity concerns, and escalation pathways.
• Work with and educate staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations and process improvements.
• Coordinate appropriate status determinations using InterQual and Medicare guidelines.
• Review payer communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalate potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
• Assist with clinical support for complex, specialized billing and follow-up workflows including but not limited to:
  • RAC correspondence and appeal processing, as well as other audit reviews,
  • advanced billing procedures requiring extensive communication with other departments, and
  • consecutive account processing and Medicare A/B split claims processing.
• Develop and maintain departmental dashboards, performance reports, and key performance indicators to monitor utilization management effectiveness, regulatory compliance, denial trends, and operational outcomes.
• Utilize data-driven insights to recommend, implement, and evaluate initiatives aimed at improving utilization review practices, reducing avoidable denials, and supporting organizational financial and quality outcomes.
• Support director in other related responsibilities as requested.
• Respond to patient and family inquiries regarding denials.
• Serve as a resource, maintain expertise and continue self-education by attending applicable conferences, workshops and interdisciplinary meetings.
• Utilize local, regional and national forums to continuously enhance expertise and knowledge base.
• Participate in applicable professional organizations and committees.
• Perform other related duties as requested.

• Bachelor's Degree Required; Field of Study: Nursing (must be graduate of an accredited nursing program).
• Minimum 3 to 5 Years of experience in hospital case management. Previous management of clinical appeals preferred.
• Rhode Island Registered Nurse licensure required.
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification required.
• Demonstrated competency in InterQual and/or MCG and Medicare rules and regulations.
• Knowledge and understanding of EMR functionality required. 
• Expertise in patient population needs, nursing practices, and department-specific competencies.
• Understanding of Department of Health regulations, accreditation standards, and compliance requirements.
• Application of quality improvement, risk management, and patient safety principles.
• Adherence to infection prevention and control policies and procedures.
• Proficiency in nursing documentation standards and regulatory requirements.
• Understanding of the Nurse Practice Act and professional nursing standards.
• Preparedness for disaster response, emergency management, and customer service excellence.