Job Summary 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.
Essential Functions - 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.
Knowledge/Skills/Abilities/Expectations - 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.
- Approximate percent of time required to travel: N/A
QualificationsEducation- Postsecondary certificate, diploma, or program graduation from an accredited school of nursing. (Required)
Or - Associate's Degree in healthcare or a related field. (Required)
- Bachelor's Degree in healthcare or a related field. (Preferred)
- Equivalent combination of education and experience in lieu of formal education (three or more years in a related field). (May be considered)
Licenses/Certifications- Healthcare licensure may be preferred unless required by the state of practice. (Preferred upon hire)
- In lieu of licensure, three (3) or more years of experience in a related healthcare field may be considered.
Experience- Three (3) or more years of experience in a healthcare setting. (Preferred)
- Prior experience in managed care, case management, utilization review, or discharge planning. (Preferred)
