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 – Pre-Admission Authorizations plays a vital role in ensuring patients receive timely access to Specialty Hospital services by managing all pre-admission authorization activities. This position partners closely with Business Development, referral sources, managed care organizations, and facility leadership to obtain prior authorizations, validate medical necessity, and secure financial clearance before admission. Serving as the primary liaison throughout the referral authorization process, the UMM Pre-Admit coordinates with referral hospitals, physicians, and payers to ensure authorization requests are complete, accurate, and processed within regulatory timeframes. Through proactive communication, clinical review, and payer collaboration, this role helps reduce admission delays, improve referral conversion, and protect organizational revenue integrity. This position actively contributes to quality improvement, operational efficiency, and exceptional patient access while supporting the organization's mission of delivering high-quality patient care.
Essential Functions
- Reviews referrals for clinical and financial approval in accordance with organizational Care Considerations.
- Reviews medical records from referral sources to determine medical necessity for admission.
- Applies InterQual, Milliman, Medicare, Medicaid, and commercial payer guidelines to support authorization requests.
- Coordinates all pre-admission prior authorization activities with managed care organizations.
- Acts as primary liaison between Business Development, referral sources, physicians, and payers throughout the authorization process.
- Obtains and documents authorization determinations in applicable systems.
- Facilitates physician-to-physician discussions and peer-to-peer reviews when required.
- Initiates reconsiderations and appeals for denied pre-admission authorizations.
- Coordinates Letters of Agreement (LOAs) and other payer-specific approval requirements as needed.
- Communicates authorization status and financial clearance to admissions teams and facility leadership.
- Ensures authorization requests meet regulatory and contractual turnaround requirements.
- Maintains current knowledge of payer requirements, authorization guidelines, and regulatory standards.
- Participates in ongoing quality improvement and process enhancement initiatives.
- Performs other duties within the scope of the CAAT team.
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.
- Expectations:
- 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
Pay Range: $66,700-$100,500/yr.
ScionHealth has a comprehensive benefits package for benefit-eligible employees that includes Medical, Dental, Vision, 401(k), FSA/HSA, Life Insurance, Paid Time Off, and Wellness.
Education
- Associate’s Degree in healthcare, nursing, business, or related field (clinical area preferred) (Required)
- Bachelor’s Degree in healthcare, nursing, business, or related field (clinical area preferred) (Preferred)
Licenses/Certifications
- Other: Healthcare professional licensure* Upon Hire (Preferred)
- 3+ years of experience in relevant field may be substituted for clinical licensure. (only in states that don't require licensure) Upon Hire
Experience
- 3+ years experience in a healthcare (Strongly Preferred)
- Prior Experience in managed care, case management, utilization review, or discharge planning a plus.
Additional Qualifications Clarification
- 3+ years of experience in relevant field may be substituted for clinical licensure. (only in states that don't require licensure)
Associate's degree in healthcare, nursing, business or related field required; Bachelor's preferred; 3+ years healthcare experience strongly preferred; managed care, case management, utilization review or discharge planning a plus; fluent English; Microsoft Office proficiency.
Key Responsibilities
- managing pre-admission authorizations
- reviewing medical records
- coordinating payer approvals
Skills & Tools
Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Outlook
Job Details
- Category: Healthcare Services - Allied Health
- Seniority: Mid Level
- Commitment: Full Time
- Workplace: Remote — United States
- Salary: USD 66,700 – 100,500 / year
- Languages: English
Benefits
- Generous paid time off
- Retirement plan
About ScionHealth
A healthcare organization empowering caregivers and providing high-quality patient care. — Industry: Healthcare