Utilization Management Manager, PRN - Remote

Description

At Scion Health
, 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.

• 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 Scion Health 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.

• Extrapolates and summarizes essential medical information to obtain authorization for admission and continued stay to/at Scion Health Level of Care.
• Prepares recommendations to submit timely request for reconsideration of denial determination in attempt to have denied authorization requests overturned.
• Ensures authorization requests are processed timely to meet regulatory time frames.
• 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.
• 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.
• Coordi…