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Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals.

On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country.

Job Summary

The Manager, Medical Necessity Review & Appeals is responsible for overseeing the evaluation of medical necessity, appropriateness, and cost-effectiveness of healthcare services, as well as managing the appeals process for denied claims. This role ensures compliance with federal, state, and payer regulations while implementing strategies that improve approval rates, reduce denials, and support optimal patient care. The Manager collaborates with clinical and operational leaders, and drives process improvements to enhance quality and financial performance.

Job Requirements

Minimum Education Requirement :

Completion of approved vocational nursing program. Bachelor’s degree in Nursing (BSN) preferred.

Minimum Experience Requirement :

Minimum of two (2) years of recent acute clinical experience and/or two years in Case Management, Utilization Review, payer appeals or related programs required. Experience with medical necessity reviews, utilization management, and/or managed care or commercial payers is preferred. Strong communication, organizational, decision-making, and prioritization skills, self-motivated and results-oriented. Able to work professionally with physicians, nurses, staff, external agencies, and patients delivering excellent customer service. Proficient in EMR systems (e.g., Meditech) and utilization review software (InterQual, MCG). Skilled in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) for data analysis, reporting, and presentations. Ability to extract, analyze, and interpret large datasets for operational decision-making. Experienced in preparing structured reports for regulatory agencies, payers, and internal departments.

Minimum License Requirement :

 California RN or LVN license. RN license is preferred.

Delivering world-class health care one patient at a time.

Pay Range: