General Summary:

The Utilization Management & Appeals Quality Improvement Specialist serves as a subject matter expert in utilization management, clinical appeals, and quality improvement related to payer authorizations and denials. This critical role collaborates with utilization management leadership on key initiatives to streamline workflows, reduce clinical denials, optimize reimbursement, and elevate documentation quality across the continuum of care. This position ensures that utilization management and appeals processes comply with the Centers for Medicare and Medicaid Services (CMS) regulatory guidelines along with Maryland Medicaid regulations, align with payer-specific requirements, and reflect best practices. The Quality Improvement Specialist will help to drive strategic improvements in the appeals process by leveraging data insights, optimizing operations, and enhancing clinical documentation to support sound medical necessity decisions and successful appeals outcomes.

Knowledge, Skills, and Abilities Required:

• Work requires comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services and knowledge of utilization review practices and procedures - acquired through a bachelor's degree in nursing, healthcare administration, or related clinical field.
• Requires an active Registered Nurse license in the state of Maryland at time of hire and must maintain licensure throughout employment.
• Work requires a minimum of 3 years of experience in utilization review, case management, appeals, or quality improvement.
  
  • Strong knowledge of payer requirements, clinical guidelines, and regulatory standards.
  • Proven ability to analyze complex clinical documentation and craft persuasive medical necessity arguments.
  • Experience developing policies, workflows, and educational materials.
  • Exceptional communication, organizational, and analytical skills.
  • Familiarity with denial management software or appeals tracking tools.

Benefits:

At Sheppard Pratt, you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

• A commitment to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation
• Comprehensive medical, dental and vision benefits for benefit eligible positions
• 403b retirement match
• Generous paid-time-off for benefit eligible positions
• Complimentary Employee Assistance Program (EAP)
• Generous mileage reimbursement program

Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.

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Equal Opportunity Employer

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