Utilization Management Manager

Job Summary

Managing pre-admission authorization activities, the full-time remote Utilization Management Manager will ensure timely patient access to Specialty Hospital services by coordinating with referral sources, managed care organizations, and facility leadership to secure financial clearance and validate medical necessity.

Key responsibilities

• Oversee the review of referrals for clinical and financial approval in line with organizational standards
• Act as the primary liaison between Business Development, referral sources, physicians, and payers throughout the authorization process
• Initiate reconsiderations and appeals for denied pre-admission authorizations while maintaining compliance with regulatory standards

Required qualifications

• Associate's Degree in healthcare, nursing, business, or related field (clinical area preferred)
• 3+ years of experience in healthcare, with a preference for experience in managed care, case management, or utilization review
• Knowledge of medical necessity justification and payer guidelines, including InterQual and Milliman
• Strong relationship-building and communication skills
• Healthcare professional licensure preferred, with experience potentially substituting for licensure in certain states