Utilization Manager

Pioneer Human Services•Burlington, WA

2d•$80,168 - $97,932

About The Position

If you are looking for employment with a purpose where you can help improve the daily lives of the members of your community, then consider a career with Pioneer Human Services! We are currently looking for a Utilization Manager with a passion for human services. This is an exciting opportunity to be involved with an organization focused on a transformative path towards social change, creating pathways for rehabilitation, reintegration, and redemption. Who we are – Our Mission We empower justice-involved individuals to overcome adversity and reach their full potential. For over 60 years, we have proudly serviced our clients with professionalism and empathy. We are a nationally recognized non-profit with 35+ locations across Washington state that provided a chance for change to over 9,500 individuals in 2024. What We Offer At Pioneer, our employees are important. That’s why we offer a Total Rewards package that includes compensation and benefits to support employees' health, security, and balance. The goal of the Utilization Management team is to control costs, improve revenue collection, and ensure data integrity. The Utilization Review (UR) Manager will critically examine guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely and accurate payment. This position works closely with clinical, leadership and administrative staff to ensure Pioneer receives accurate and timely payment for services provided. The UR Manager is responsible for maintaining and reporting on all residential utilization metrics, outcomes, and overall efficiency of the program. The UM manager works with multi-disciplinary teams to ensure that documentation and processes meet internal and external standards and align with industry best practices.

Requirements

2 year of responsible leadership experience in management or supervisory positions
Experience with medical billing and/ or coding
Familiarity with insurance company processes
2 years of Utilization Management experience and/or knowledge of psychiatric/behavioral health systems
3 years of experience working with individuals with behavioral health conditions
2 year of responsible leadership experience in management or supervisory positions
Experience with medical billing and/ or coding
Familiarity with insurance company processes
2 years of Utilization Management experience and/or knowledge of psychiatric/behavioral health systems
3 years of experience working with individuals with behavioral health conditions

Nice To Haves

Credentialed as MHP, SUDP, RN or ARNP
Experience working in a residential treatment facility
Master’s degree in health care, business or related field

Responsibilities

Provides leadership, guidance, training, and communication to assigned staff
Analyzes data to identifies trends and challenges; identifies, proposes, and implements solutions
Tracks workload and workflow processes to ensure timely processing of authorizations
Negotiates and coordinates length of stay
Ensures accurate and timely data collection
Reviews treatment plans to ensure proper documentation, continuity of care, and compliance
Reviews client records using utilization criteria to ensure medical necessity and determine need for continuing treatment
Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
Reviews bed boards daily to ensure accuracy
Ensures initial authorizations, episodes, and bed boards are completed in a timely and accurate manner
Monitors, tracks, and analyzes required reports
Maintains applicable UR documentation in Electronic Medical Record (EMR)
Conducts peer-to-peer review with MCO to appeal denials
Submits appeals for denied authorizations with applicable clinical, demographic, and payer information
Coordinates, monitors, and tracks resolution of revenue cycle tickets to help resolve funding and other related, non-clinical, client issues
Ensures clients have access to services while ensuring the client’s right to be in the least restrictive environment as clinically appropriate
Understands and applies MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment status
Ensures excellent customer service is provided to payers, vendors, and internal customers
Maintains access to Quick Mar, EHR, payer portals and other required systems
Communicates regularly with payor and program leadership to establish and maintain working relationships to address issues, barriers, and challenges timely and efficiently
Negotiates length of stay with payers 2 year of responsible leadership experience in management or supervisory positions
Collaborates with clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs
Coordinates with health plan organizations, hospitals, doctors, and pharmacists to ensure services are covered and to improve treatment outcomes
Composes and sends professional communication related to medical records and case coordination
Monitors and provides appropriate staff updates for authorizations and length-of-stay; assists with transition for continued stays, discharges, or transfers
Collaborates and partners with billing, clinical staff, management, UM team, and finance to ensure data accuracy, operational efficiency, timely financial collection, and adequate task coverage
Maintains working knowledge and collaborative relationships with community partners and resources
Promotes and models teamwork and collaboration with coworkers
Maintains quality of care consistent with or exceeding standards set by federal, state, local, internal, and contract requirements
Adheres to professional and ethical standards for behavioral health services
Develops internal policies and procedures
Guides staff in proper completion of clinical documentation to ensure accuracy and quality client care
Maintains current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and other related industry programs and practices
Assists with training staff to ensure operational efficiency

Benefits

Medical
Flexible spending
Dental
Vision
Life
AD&D
Disability
Dependent Daycare Flexible Spending
Tuition assistance (100% for bachelor's, 50% for graduate programs)
Retirement plan (3.5% annual compensation contribution, plus 3.5% match for 6% individual contribution)
Employee recognition programs
Public transportation discount
Employee assistance program (EAP)