Utilization Management Lead: Access & Appeals Strategy

Socket.dev; Philadelphia (Philadelphia County); Remote; USD 90,000 - 130,000; Full time

Job summary

ScionHealth is seeking an Utilization Management Manager to oversee pre-admission prior authorizations and in-house concurrent review authorizations. The role requires strong clinical knowledge, regulatory understanding, and collaborative skills to secure timely authorizations and coordinate with hospitals, case management, and payors.

You will drive efficient authorization processes, contribute to quality improvement, and ensure adherence to regulatory timeframes while safeguarding revenue

Qualifications

• Requires strong knowledge of clinical utilization management and regulatory guidelines.
• Familiarity with Medicare, Medicaid and managed care payment methodologies.
• Excellent written and verbal communication for appeals and denials.

Responsibilities

• Extrapolates medical information to obtain authorization for admission and continued stay.
• Prepares recommendations for reconsideration of denial determinations.
• Ensures authorization requests meet regulatory timeframes.
• Reviews case management assessments for severity of illness and level of care.
• Generates appeals for denials based on medical necessity.
• Documents authorization details in tracking systems.
• Coordinates with Business Development, admissions and managed care teams.
• Facilitates pre-admission prior authorizations and concurrent review authorizations.
• Liaises with physicians, payors and facility administration through the authorization process.
• Maintains knowledge of responsibilities and pursues continuing education.
• Supports optimization of CAAT Admission Processes and related initiatives.

Skills

Relationship building

Regulatory knowledge

Medicare/Medicaid knowledge

Clinical utilization management

InterQual/Milliman knowledge

Microsoft Office

Education

Postsecondary certificate

Associate degree

Bachelor’s degree

Equivalent combination of education and experience

Tools

Microsoft Office

Job description

ScionHealth is seeking an Utilization Management Manager to oversee pre-admission prior authorizations and in-house concurrent review authorizations. The role requires strong clinical knowledge, regulatory understanding, and collaborative skills to secure timely authorizations and coordinate with hospitals, case management, and payors.

You will drive efficient authorization processes, contribute to quality improvement, and ensure adherence to regulatory timeframes while safeguarding revenue