Utilization Management Manager Post Admissions Remote

ScionHealth • Las Vegas, NV

2d • Remote

About The Position

The Utilization Management Manager manages front-end prior authorizations and in-house concurrent review authorizations to support timely access to care, reduce delays, and safeguard revenue integrity. The role reviews prospective, retrospective, and concurrent medical records; coordinates prior authorizations with referring hospitals; and partners with case management teams at ScionHealth facilities to complete concurrent review authorizations. It serves as a liaison among Business Development, facility administration, managed care organizations, payors, and clinical teams, ensuring authorization determinations are communicated promptly and accurately.

The position contributes to quality improvement, problem-solving, and productivity initiatives within an interdisciplinary model, with accountability for operational excellence and support of the organization’s patient-care mission. It also maintains knowledge of its areas of responsibility and participates in continuing education and professional development.

Requirements

• Postsecondary certificate, diploma, or program graduation from an accredited school of nursing, or an associate degree in healthcare or a related field.
• Healthcare licensure may be preferred unless required by the state of practice; three or more years of experience in a related healthcare field may be considered in lieu of licensure.
• Strong relationship-building skills and a service-oriented approach.
• Knowledge of regulatory standards and compliance guidelines.
• Working knowledge of medical-necessity justification, including non-physician review guidelines such as InterQual and Milliman, Medicare and Medicaid rules and coverage guidelines, and NCDs and LCDs.
• Working knowledge of Medicare, Medicaid, and managed-care payment methodologies.
• Extensive knowledge of clinical symptomology, related treatments, and hospital utilization management.
• Excellent interpersonal, verbal, and written communication skills to obtain cooperation and collaboration from hospital leadership, physicians, payors, and external customers.
• Critical-thinking, problem-solving, and decision-making capabilities, including the ability to collect, organize, evaluate, and communicate pertinent clinical information.
• Technical writing skills for appeal letters and reports.
• Effective time-management and prioritization skills.
• Computer skills and working knowledge of Microsoft Office, including Word, Excel, PowerPoint, and Outlook, as well as word-processing and spreadsheet software.
• Good interpersonal skills when interacting with patients, families, and staff members.
• Professional conduct consistent with company standards, policies, procedures, compliance requirements, applicable laws, and professional standards.
• Fluent in reading, writing, and speaking English.
• Good and regular attendance.

Nice To Haves

• Bachelor’s degree in healthcare or a related field.
• Three or more years of experience in a healthcare setting.
• Prior experience in managed care, case management, utilization review, or discharge planning.
• Healthcare licensure, unless required by the state of practice.

Responsibilities

• Summarize essential medical information to obtain authorization for admission and continued stay at a ScionHealth level of care.
• Prepare timely recommendations for reconsideration of denied authorization determinations and generate written appeals for medical-necessity denials.
• Ensure authorization requests are processed within regulatory timeframes and document authorization information in relevant tracking systems.
• Review medical-necessity assessments completed by case management, evaluating documentation for severity-of-illness criteria and level-of-care appropriateness.
• Build relationships with Business Development, admissions, clinical staff, and managed care teams to coordinate patient admissions.
• Support review of patient referrals for clinical and financial approval, escalating to leadership as appropriate under the Care Considerations grid.
• Coordinate pre-admission prior authorizations by identifying medical records needed from referring facilities and applying appropriate clinical guidelines.
• Communicate patient needs for equipment, supplies, and consult services related to prior authorization requirements.
• Act as a liaison with Business Development throughout the authorization process, initiate appeals as appropriate, and facilitate physician-to-physician communication for denial management.
• Notify Business Development and facility administration when clinical authorization and financial approval are complete, and provide hospital teams with prior authorization information for pending and new admissions.
• Coordinate with managed care payors on coverage issues and support the letter-of-agreement process as requested.
• Coordinate concurrent review authorizations for patients in ScionHealth facilities by obtaining and reviewing required medical records and applying clinical guidelines.
• Review medical-necessity information from case management, communicate additional questions or information requests, and liaise with case management through authorization determinations.
• Initiate concurrent-review appeals as appropriate and communicate with managed care medical advisors or case managers, including during care coordination and managed care calls.
• Maintain knowledge of areas of responsibility, participate in continuing education and professional development, and develop knowledge of CAAT admission processes while seeking to improve them.
• Conduct job responsibilities in accordance with company policies, compliance requirements, applicable laws, and professional standards; maintain a professional image and adhere to ScionHealth policies.
• Maintain good and regular attendance and communicate fluently in English.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree