Utilization Management Manager Post Admissions Remote

Kindred Healthcare • Las Vegas, NV

3d • Remote

About The Position

The Utilization Management Manager oversees prior authorization and concurrent review authorization activities to support timely patient access to care and seamless transitions. 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 reviews. It serves as a liaison among Business Development, facility administration, case management, managed care organizations, and payors, ensuring authorization determinations are communicated promptly and accurately.

The manager supports revenue integrity and reduces authorization delays while contributing to quality improvement, problem-solving, productivity, and operational excellence within an interdisciplinary model. Responsibilities include applying clinical guidelines, assessing medical necessity and level-of-care appropriateness, preparing reconsiderations and appeals for denials, documenting authorization information, supporting referral reviews and approval escalations, and coordinating with payors on coverage issues and letters of agreement. The role also requires maintaining relevant knowledge through continuing education and ongoing improvement of CAAT Admission Processes.

Requirements

• Postsecondary certificate, diploma, or program graduation from an accredited school of nursing, or an associate degree in healthcare or a related field.
• Three or more years of experience in a related field may be considered in lieu of formal education.
• Strong relationship-building skills and a service-oriented approach.
• Knowledge of regulatory standards and compliance guidelines.
• Working knowledge of medical-necessity guidelines, including InterQual and Milliman, and Medicare and Medicaid rules, coverage guidelines, 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 skills, 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.
• Ability to read, write, and speak fluent English.
• Good interpersonal skills when interacting with patients, families, and staff.
• Healthcare licensure may be preferred unless required by the state of practice; three or more years of related healthcare experience may be considered in lieu of licensure.

Nice To Haves

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

Responsibilities

• Summarize essential medical information to obtain authorization for admission and continued stay at the appropriate ScionHealth level of care.
• Prepare recommendations and timely reconsideration requests seeking to overturn denied authorization requests.
• Ensure authorization requests are processed within regulatory timeframes.
• Review case management medical-necessity assessments and documentation for severity-of-illness criteria and level-of-care appropriateness.
• Prepare written appeals for medical-necessity-based denials involving pre-admission and concurrent review authorizations, using clinical and regulatory knowledge.
• Document authorization information in relevant tracking systems.
• Build relationships with Business Development, admissions, clinical staff, and managed care teams to coordinate patient admissions.
• Support clinical and financial review of patient referrals and escalate cases to leadership for approval according to the Care Considerations grid.
• Coordinate pre-admission prior authorizations, including identifying needed records, applying clinical guidelines, communicating patient needs related to equipment, supplies, and consult services, and liaising with Business Development through determination.
• Initiate appeals as appropriate and facilitate physician-to-physician communication for denial management when appropriate.
• Notify relevant teams, including Business Development and facility administration, when clinical authorization and financial approval are complete, and provide hospital teams with prior authorization information for pending or 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 at ScionHealth facilities, including obtaining needed records, applying clinical guidelines, reviewing case management information, and communicating additional questions or information requests.
• Liaise with Case Management throughout concurrent review authorization determinations and communicate with managed care medical advisors or case managers as needed, including during Care Coordination and Managed Care calls.
• Maintain knowledge of assigned responsibilities, participate in continuing education and professional development, and learn and continuously improve CAAT Admission Processes.
• Follow the Company’s Code of Business Conduct, policies and procedures, Corporate Compliance Agreement, applicable laws, professional standards, and ScionHealth policies and practices.
• Maintain good and regular attendance and communicate and conduct oneself professionally with patients, families, coworkers, clients, and others.

What This Job Offers

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