Jobs in the United States

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Added 2 mins ago
Construction Program Manager 5
Manpower Engineering
Pecos, TX
Our client, Construction Management is seeking a Construction Program Manager 5 to join their team. As a Construction Program Manager 5, you will be part of the Construction Program…
Added 2 mins ago
Quality Engineering Manager
Teva Pharmaceutical
Salt Lake City
Proactively works on problems of a complex scope where evaluation of contributing factors requires the analysis of situations or data and an in-depth knowledge and evaluation of various…
Added 2 mins ago
Tile Department Manager
Floor and Decor Outlets of America, Inc.
Wilmington, NC
Ability to perform in a high volume, highly complex location.
Added 3 mins ago
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Assistant Project Manager
Actalent
Newtown, PA
- $30 to $45 USD / hour
Job Title: Assistant Project Manager Commercial & Higher Education ConstructionJob DescriptionThe Assistant Project Manager supports the planning, coordination, and execution of commercial…
Added 3 mins ago
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Pharmacy Technician
CVS Health
Montgomery, AL
- $16 to $24 USD / hour
As a new Pharmacy Technician, you are required to complete an extensive CVS Pharmacy Technician Training Program as well as satisfy all registration, licensing and certification…
Added 4 mins ago
Transformation Delivery Project Manager - Associate Director
DTCC Candidate Experience
Jersey City, NJ
The Project Manager – Associate Director is a senior delivery role within the Enterprise Transformation organization, accountable for the successful management of complex initiatives that…
Added 5 mins ago
Supervisor, Operations QA
ConnectiveRx
Pittsburgh, PA
…part. Getting prescriptions to patients has become increasingly complex. When things get messy along the prescription journey, pharmaceutical manufacturers rely on us to untangle the…
Added 6 mins ago
Sr. Principal System Engineer - USAF IFC Manager
CORP-Corporate Office
United States
…reduce integration risk and enable predictable, high-quality program execution. You will be working across the entire spectrum of the Systems Engineering V-Model, and will support SE…
Added 6 mins ago
Principal Water/Wastewater Engineer
Arcadis
Sewickley, PA · Pittsburgh, PA
…many curious minds, together we can solve the world’s most complex challenges and deliver more impact…
Added 6 mins ago
Transportation Industry Growth Accelerator – Americas
Arcadis
Irvine, CA
…many curious minds, together we can solve the world’s most complex challenges and deliver more impact…
Added 7 mins ago
CC
General Manager
Community Choice Financial Family of Brands
Decatur, GA
- $19.25 USD / hour
As a General Manager (GM), you’ll provide reliable financial solutions to help customers manage everyday challenges. As the driving force behind the store’s success, you’ll manage daily…
Added 7 mins ago
CC
General Manager
Community Choice Financial Family of Brands
Norcross, GA
- $19.25 USD / hour
As a General Manager (GM), you’ll provide reliable financial solutions to help customers manage everyday challenges. As the driving force behind the store’s success, you’ll manage daily…
Added 7 mins ago
Pediatric Nurse PICU Weekend program days or nights
CHS Children's Hospital and Health System, Inc.
Milwaukee, WI
…unit/area and division of nursing goals. Works with patient care manager to identify possible areas for operational and capital budgeting considerations. Education: - Associate's Degree ADN…
Added 7 mins ago
Sourcing Co-Op Spring 2027
Emerson
Elyria, OH
Supplier Delivery Get Well Program – create open order documents for the weekly meetings and run the Get Well meetings with the suppliers over time.
Added 8 mins ago
Vegetation Program Manager - Central Coast
Pacific Gas And Electric Company
San Luis Obispo, CA
The Vegetation Program Manager oversees Vegetation Management operations, ensuring electric system safety, reliability and regulatory compliance with state and federal rules. The incumbent…
Added 8 mins ago
Advanced Project Manager
Westinghouse Electric Company, LLC
Cranberry Township, NC
As a Principal Project Manager you will manage high-complexity projects with substantial financial, technical, and customer commitments. Direct multidisciplinary teams across departments…
Added 8 mins ago
CC
General Manager
Community Choice Financial Family of Brands
Decatur, GA
- $19.25 USD / hour
As a General Manager (GM), you’ll provide reliable financial solutions to help customers manage everyday challenges. As the driving force behind the store’s success, you’ll manage daily…
Added 8 mins ago
SAP Analyst
Magna Steyr USA Inc.
Mesa, AZ
· Coordinate complex technical issues with corporate/global SAP teams and other IT support resources.
Added 9 mins ago
Design Integration Manager
Samet Corporation
Greensboro, NC · Charlotte, NC · Raleigh, NC
As Design Integration Manager, you’re the link between what’s drawn and what gets built. You’ll work with architects, engineers, consultants, clients, and our construction teams to turn…
Added 9 mins ago
Superintendent
DAVIS
Rockville, MD
Maintains positive relationships with owners, vendors, architects, engineers, and consultants property manager, building engineer, owner's rep or development manager; addresses concerns…
Added 10 mins ago
Propulsion Automation Validation Lead
Stellantis
Auburn Hills, MI
…Artificial Intelligence (AI/LLM) into testing pipelines, defining complex regulatory/diagnostic test standards, and managing cross-functional validation…
Added 11 mins ago
Enterprise Customer Success Manager
IMPLAN Group LLC
Remote, United States
We are looking for an Enterprise Customer Success Manager (CSM) who is passionate about helping IMPLAN's largest customers get lasting value from IMPLAN software and economic analysis.…
Added 11 mins ago
Vegetation Program Manager - Central Coast
San Luis Obispo, SC
The Vegetation Program Manager oversees Vegetation Management operations, ensuring electric system safety, reliability and regulatory compliance with state and federal rules. The incumbent…
Added 12 mins ago
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Small Business Navigator
Frederick County Government
Frederick, MD
- $91,314.33 to $155,234.36 USD / year
This position serves as the lead coordinator and project manager for Division of Planning and Permitting, overseeing planning, development review, zoning, permitting and inspection…
Added 12 mins ago
Staff Development Manager
Agency on Aging of South Central CT
North Haven, CT
The Staff Development Manager is responsible for assisting in the development and implementation of a training program that prepares new employees to meet the needs of the clients we serve…

ScionHealth

Utilization Management Manager Post Admissions Remote

Las Vegas, NV, United States

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Job details

Posting language: English

Original job description

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates. 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

Education

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)

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