Role Description

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.

• Drives the authorization process—reviewing prospective, retrospective, and concurrent medical records.
• Coordinates with referring hospitals to secure prior authorizations.
• Partners with case management teams at ScionHealth facilities to complete concurrent review authorizations.
• Acts as a navigator and liaison between Business Development, facility administration, managed care organizations, and payors.
• Safeguards revenue integrity, reduces delays, and supports the organization’s mission of delivering exceptional patient care.
• Contributes to quality improvement, problem-solving, and productivity initiatives within an interdisciplinary model.

Qualifications

• 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 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.
• Critical thinking, problem solving, and decision-making capabilities.
• 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).
• Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members.
• Must read, write, and speak fluent English.
• Must have good and regular attendance.

Requirements

• Postsecondary non-Degree (Cert/Diploma/Program Grad) of an Accredited School of Nursing required.
• Associate’s Degree in healthcare or related field required.
• Bachelor’s Degree in healthcare or related field preferred.
• Equivalent combination of Education and/or Experience in lieu of education (3+ years in a related field) may be considered.
• Healthcare professional licensure preferred.
• In lieu of licensure, 3+ years of experience in relevant field required.
• Some states may require licensure or certification.
• 3+ years of experience in a healthcare strongly preferred.
• Experience in managed care, case management, utilization review, or discharge planning a plus.

Benefits

• Comprehensive benefits package for benefit-eligible employees.
• Includes Medical, Dental, Vision, 401(k), FSA/HSA, Life Insurance, Paid Time Off, and Wellness.

Pay Range

$66,700-$100,500/yr.