Job Summary The Director, Post-Admission Authorization provides strategic leadership and operational oversight for all concurrent review authorization activities across ScionHealth Specialty Hospitals. This role is responsible for ensuring timely payer authorization approvals throughout a patient's stay, minimizing authorization-related denials, and supporting optimal reimbursement through proactive management of continued stay reviews. The Director leads and develops the Concurrent Review team, including Utilization Management staff and authorization specialists responsible for securing and maintaining payer approvals. This position establishes system-wide standards, drives accountability, and promotes best practices related to concurrent review processes, payer communication, and authorization management. The Director partners closely with CAAT (Central Access and Authorizations Team), Case Management, Revenue Cycle, Managed Care, Business Development, and facility leadership to improve authorization outcomes, reduce avoidable denials, and ensure patients continue to receive medically necessary care without interruption. Through strong leadership, process improvement, data analysis, and payer collaboration, this role supports operational excellence and organizational financial performance.
Essential Functions - Provide strategic oversight for concurrent review authorization processes across the Specialty Hospital Division.
- Lead and develop team members responsible for continued stay authorizations, concurrent review activities, and payer communication.
- Establish standardized workflows, escalation pathways, performance metrics, and operational expectations related to concurrent review authorization management.
- Monitor authorization status for ongoing patient stays and ensure timely submission of clinical documentation to support medical necessity and continued stay determinations.
- Identify, escalate, and resolve authorization barriers that may impact patient care, length of stay, reimbursement, or patient throughput.
- Partner with facility Utilization Management teams to ensure accurate, timely, and complete clinical reviews are submitted to payers.
- Analyze authorization trends, payer behavior, continued stay denials, and authorization gaps to identify opportunities for improvement and risk mitigation.
- Develop, monitor, and report key performance indicators (KPIs) related to authorization success rates, authorization turnaround times, payer responsiveness, denial prevention, and concurrent review effectiveness.
- Collaborate with Revenue Cycle, Case Management, and Denials Management teams to reduce authorization-related write-offs and preventable denials.
- Serve as the primary liaison to Managed Care, Payor Relations, and payer representatives regarding concurrent review processes, authorization requirements, escalated cases, and contract interpretation impacting continued stay approvals.
- Ensure timely and accurate communication of payer determinations, authorization status updates, and escalation needs to facilities, CAAT leadership, and business development teams.
- Build collaborative relationships with payer representatives to improve communication, resolve escalated authorization issues, and strengthen authorization outcomes.
- Lead training and education initiatives related to payer guidelines, documentation requirements, medical necessity criteria, and concurrent review best practices.
- Collaborate with Case Management, Business Development, and facility leadership to support efficient patient admissions, transitions of care, and authorization continuity throughout the patient stay.
- Ensure compliance with all regulatory, contractual, accreditation, and organizational standards related to utilization management and authorization processes.
- Promote a culture of accountability, continuous improvement, service excellence, and cross-functional collaboration.
- Perform other duties as assigned within the scope of the CAAT organization.
Knowledge/Skills/Abilities/Expectations - Expertise in medical necessity guidelines, Medicare/Medicaid regulations, and managed care processes.
- Strong leadership skills with ability to manage remote and facility-based teams.
- Excellent written and verbal communication skills, including technical writing for appeals.
- Analytical and problem-solving skills, with ability to identify trends and implement system-level solutions.
- Ability to manage multiple priorities with a focus on timely execution and measurable outcomes.
- Proficiency in Microsoft Office and EMR/utilization management platforms.
- 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
- Will report to a building; may cover more than one building depending on market alignment and structure
- Approximate percent of time required to travel: 0%
QualificationsEducation - Bachelor's Degree in healthcare, nursing, business, or related field (Required) And
- Master's Degree in healthcare, nursing, business, or related field (Preferred)
Licenses/Certifications - Other: Active clinical licensure (RN, LPN, or related) Upon Hire (Preferred)
- Experience in managed care or utilization management in lieu of clinical licensure may be considered.
Experience - 7-9 years experience in utilization management, managed care, case management, or related field
- 3+ years leadership experience overseeing teams or multi-site operations
- Prior Experience and demonstrated success in denial management, appeals, and payer relations
Additional Qualifications Clarification - Experience in managed care or utilization management in lieu of clinical licensure may be considered.
