Utilization Management Manager

Kindred Healthcare•Philadelphia, PA

63d

About The Position

The Utilization Management Manager plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position blends strong relationship-building skills with clinical knowledge to navigate complex payer requirements, streamline the authorization process, and support seamless patient transitions. From start to finish, this role drives the authorization process—reviewing prospective, retrospective, and concurrent medical records; coordinating with referring hospitals to secure prior authorizations; and partnering with case management teams at ScionHealth facilities to complete concurrent review authorizations. Acting as a navigator and liaison between Business Development, facility administration, managed care organizations, and payors, the specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders. By combining attention to detail with proactive collaboration, the Utilization Management Manager safeguards revenue integrity, reduces delays, and supports the organization’s mission of delivering exceptional patient care. This role actively contributes to quality improvement, problem-solving, and productivity initiatives within an interdisciplinary model, demonstrating accountability and a commitment to operational excellence.

Requirements

Strong relationship building skills and a spirit to serve to ensure effective communication and service excellence
Knowledge of regulatory standards and compliance guidelines
Working knowledge of medical necessity justification through but not limited to non-physician review guidelines (InterQual and Milliman), Medicare and Medicaid rules, regulations, coverage guidelines, NCDs and LCDs
Working knowledge of Medicare, Medicaid and Managed Care payment and methodology
Extensive knowledge of clinical symptomology, related treatments and hospital utilization management
Excellent interpersonal, verbal and written skills to communicate effectively and to obtain cooperation/collaboration from hospital leadership, as well as physicians, payors and other external customers
Critical thinking, problem solving, and decision-making capabilities with the ability to discern, collect, organize, evaluate, and communicate pertinent clinical information with effective verbal and written skills.
Technical writing skills for appeal letters and reports
Effective time management and prioritization skills
Computer skills with working knowledge of Microsoft Office (Word, Excel, PowerPoint, and Outlook), word-processing and spreadsheet software
Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members
Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards
Communicates and demonstrates a professional image/attitude for patients, families, clients, coworkers and others
Adheres to policies and practices of ScionHealth
Must read, write, and speak fluent English
Must have good and regular attendance
Associate degree required
Healthcare professional licensure preferred
In lieu of licensure, 3+ years of experience in relevant field required
Some states may require licensure or certification
3+ years of experience in a healthcare strongly preferred

Nice To Haves

Bachelor’s degree preferred
Clinical area strongly preferred
Experience in managed care, case management, utilization review, or discharge planning a plus

Responsibilities

Extrapolates and summarizes essential medical information to obtain authorization for admission and continued stay to/at ScionHealth Level of Care
Prepares recommendations to sumbit timely request for reconsideration of denial determination in attempt to have denied authorization requests overturned
Ensures authorization requests are processed timely to meet regulatory timeframes
Reviews medical necessity assessments completed by case management, evaluating documentation for specific criteria related to severity of illness, and level of care appropriateness
Generates written appeals to medical necessity-based payor denials for denials prior to admission and concurrent review authorizations. Appeal letters may be processed on behalf of the physician, combining clinical and regulatory knowledge in efforts to have consideration of authorization
Documents authorization information in relevant tracking systems
Effectively builds relationships with business development team, admissions team/clinical staff and managed care team, to coordinate the patient admission functions in keeping with the mission and vision of the hospital
Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Considerations grid
Coordinates and facilitates pre-admission Prior Authorizations for patients from the referral sources:
Identifies /reviews medical record information needed from referring facility.
Applies appropriate clinical guidelines to pre-authorization determination process.
Communicates specific patient needs for equipment, supplies, and consult services as related to prior authorization requirements.
Acts as a liaison with the Business Development team through every stage of the authorization process through determination.
Initiates appeals process as appropriate.
Facilitates and coordinates physician-to-physician communication as appropriate to support the denial management process.
Communicates to appropriate teams, including business development and facility administration when clinical authorization and financial approval is complete, following standard authorization process.
Provides hospital team with needed prior authorization information on pending / new admissions
Coordinate with managed care payor on all coverage issues and supports the LOA process as requested
Coordinates and facilitates Concurrent Review Authorizations for patients actively in-house at a ScionHealth facility
Identifies /reviews medical record information needed from facility.
Applies appropriate clinical guidelines to concurrent review authorization process.
Review medical necessity review information provided by the case management team and communicates any additinoal questions or information requests
Acts as a liaison with the Case Management team through every stage of the concurrent review authorization process through determination.
Initiates appeals process as appropriate.
Communicates with Medical Advisors or case managers of managed care company as necessary; including during Care Coordination / Managed Care calls
Maintains a knowledge of areas of responsibility and develops and follows a program of continuing education
Participates in continuing education/ professional development activities
Learns and develops full knowledge of the CAAT Admission Processes and actively seeks to continuously improve them