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Manager, Software Development, Private Brands
Amazon.com Services LLC
Seattle, WA
…next generation of APB products. As the Software Development Manager for the team, you'll own the vision, execution, and health of the platform, from dynamic data management and task…
Added just now
Sr. Construction Manager, WWGS Enterprise Development
Amazon.com Services LLC
CA · IL · TX · WA · CO
…other employees, supervisors, and staff; adhere to standards of excellence despite stressful conditions; communicate effectively and respectfully with employees, supervisors, and staff to…
Added 1 min ago
CD
Community Based Service Manager
CONCILIO DE ORGANIZACIONES HISPANAS
Philadelphia, PA
- $65,000 to $75,000 USD / year
The Community Based Services (CBS) Manager provides operational, financial, and programmatic leadership for Concilio’s community-based programs. Reporting to the Chief Program Officer…
Added 1 min ago
UA
Order Management Specialist
USABB ABB Inc.
Richmond, VA
- $68,600 to $109,760 USD / year
…implement customer support strategy to increase operational excellence and customer satisfaction in the sales process. You will also showcase your expertise by supporting achievement of…
Added 2 mins ago
Clinical Staff Manager- Cancer Center-FT
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Atlanta, GA
The Clinical Staff Manager (CSM), reporting to a multiple department Nursing Unit Director, is a direct supervisory leadership role that is a key member of the Nursing leadership team. The…
Added 3 mins ago
AM
Director of Clinical Services
American Mercy Home Care
Cincinnati, OH
- $45.26 to $67.32 USD / hour
EMR Workflow Completion: Guarantee that all HCHB clinical workflow for both the Director of Clinical Services (DCS) and Manager of Clinical Services (MCS) is completed and current by the…
Added 4 mins ago
Field Representative - San Francisco
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Work with the Regional Manager, Director of US Sales and Marketing & Sales department to create and implement a strategic business plan for their territory.
Added 4 mins ago
Facility Manager
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United States
We're committed to bringing passion and customer focus to the business.
Added 6 mins ago
Program Manager, Operations Process
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Gatik is looking for a detail-oriented, improvement-minded Program Manager, Operations Process to own and improve the workflows that power our autonomous trucking operations. In this role,…
Added 6 mins ago
General Manager, Account Management
HALO
Remote, United States
HALO is looking for a General Manager, Account Management, who will lead a large, multi-product account management organization and is accountable for client success, financial performance,…
Added 9 mins ago
Director, Talent and Performance Enablement
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Equip leaders to hold effective performance conversations, recognize excellence, and address underperformance fairly.
Added 9 mins ago
Hearing Aid Specialist
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Lakeland, FL · LAKELAND, FL
…people rediscover the emotions of sound. Reporting to the Area Manager, you will drive office revenue and community engagement through clinical excellence and dedicated customer…
Added 10 mins ago
Quality Manager
ThermAvant Technologies LLC
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…requirements, and other relevant aerospace standards. The Quality Manager works cross-functionally with Engineering, Supply Chain, Program Management, and Operations to drive defect…
Added 11 mins ago
Manager Project Materials
Freeport McMoRan
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At Freeport-McMoRan, we are committed to providing an employment package that recognizes excellence, encourages safe production and a culture supported by our core values. Here, you’ll find…
Added 12 mins ago
Senior MEP Manager / Systems Manager
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As a Senior MEP Systems Manager, you have the opportunity to add to that legacy by being a part of the construction process from start to finish by utilizing your knowledge to drive…
Added 15 mins ago
Nurse Manager (RN)-Vascular Telemetry-Days-Cobb
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The nurse manager is a registered professional nurse who provides leadership and management of a specific unit(s) or service through the effective use of knowledge and skills to promote the…
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…products in line with the values of our Houses, through a process of permanent…
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Senior Billing Manager
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TRIBAL PROGRAM MANAGER
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The Tribal Coordinator is responsible for collaborating with Business Development to maintain positive partnerships with referral services. The Tribal Coordinator will comply with White…
Added 17 mins ago
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Pharmacy Manager FT
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- $65 to $85 USD / hour
As a Pharmacy Manager, you will lead and develop a pharmacy team that provides exceptional patient care by promoting best practices and leading through change while identifying and…
Added 17 mins ago
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Pharmacy Technician
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- $17 USD / hour
Once in role, Technicians are required to complete a rigorous company training program and satisfy all registration, licensing, and certification requirements according to their State’s…
Added 17 mins ago
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Pharmacy Technician
CVS Health
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Once in role, Technicians are required to complete a rigorous company training program and satisfy all registration, licensing, and certification requirements according to their State’s…
Added 17 mins ago
Store Manager, RX
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As a CVS Health Store Manager Rx (SM, Rx), you will be a single-unit retail leader responsible for leading your team to achieve operational and service excellence. The SM, Rx will achieve…
Added 17 mins ago
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Pharmacy Technician
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- $17 USD / hour
Once in role, Technicians are required to complete a rigorous company training program and satisfy all registration, licensing, and certification requirements according to their State’s…
Added 17 mins ago
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Pharmacy Technician
CVS Health
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- $17 USD / hour
Once in role, Technicians are required to complete a rigorous company training program and satisfy all registration, licensing, and certification requirements according to their State’s…

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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