Utilization Manager

Job Description

Job Description

If you are looking for employment with a purpose where you can help improve the daily lives of the members of your community, then consider a career with Pioneer Human Services!

We are currently looking for aUtilization Managerwith a passion for human services. This is an exciting opportunity to be involved with an organization focused on a transformative path towards social change, creating pathways for rehabilitation, reintegration, and redemption.

Who we are – Our Mission
We empower justice-involved individuals to overcome adversity and reach their full potential.

For over 60 years, we have proudly serviced our clients with professionalism and empathy. We are a nationally recognized non-profit with 35+ locations across Washington state that provided a chance for change to over 9,500 individuals in 2024.

What We Offer

At Pioneer, our employees are important. That’s why we offer a Total Rewards package that includes compensation and benefits to support employees' health, security, and balance.

Compensation:New hires for this position typically start between$77,968.80 and $79,514.60 annually, depending on factors such as work location, experience, qualifications, skills, competencies, internal equity,and market conditions. While the full pay range is provided to support pay transparency, individual compensation will vary within the range based on these factors.Benefits:

Eligible after 30 days of full-time employment (minimum of 30 hours/week):

• Medical
• Flexible spending
• Dental
• Vision

Additional coverage after 60 days:

• Life
• AD&D
• Disability

Other benefits:

• Dependent Daycare Flexible Spending
• Tuition assistance (100% for bachelor's, 50% for graduate programs)
• Retirement plan (3.5% annual compensation contribution, plus 3.5% match for 6% individual contribution)
• Employee recognition programs
• Public transportation discount
• Employee assistance program (EAP)

Join Pioneer and be part of a team that values and invests in you.

What you'll do
The goal of Utilization Management team is to control costs, improve revenue collection, and ensure data integrity. The Utilization Review (UR) Manager will critically examine guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely and accurate payment. This position works closely with clinical, leadership and administrative staff to ensure Pioneer receives accurate and timely payment for services provided. The UR Manager is responsible for maintaining and reporting on all residential utilization metrics, outcomes, and overall efficiency of the program. The UM manager works with multi-disciplinary teams to ensure that documentation and processes meet internal and external standards and align with industry best practices.

Primary/essential duties and responsibilities are but not limited to:

• Provides leadership, guidance, training, and communication to assigned staff
• Analyzes data to identifies trends and challenges; identifies, proposes, and implements solutions
• Tracks workload and workflow processes to ensure timely processing of authorizations
• Negotiates and coordinates length of stay
• Ensures accurate and timely data collection
• Reviews treatment plans to ensure proper documentation, continuity of care, and compliance
• Reviews client records using utilization criteria to ensure medical necessity and determine need for continuing treatment

• Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
• Reviews bed boards daily to ensure accuracy
• Ensures initial authorizations, episodes, and bed boards are completed in a timely and accurate manner
• Monitors, tracks, and analyzes required reports
• Maintains applicable UR documentation in Electronic Medical Record (EMR)
• Conducts peer-to-peer review with MCO to appeal denials
• Submits appeals for denied authorizations with applicable clinical, demographic, and payer information
• Coordinates, monitors, and tracks resolution of revenue cycle tickets to help resolve funding and other related, non-clinical, client issues
• Ensures clients have access to services while ensuring the client’s right to be in the least restrictive environment as clinically appropriate
• Understands and applies MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment status
• Ensures excellent customer service is provided to payers, vendors, and internal customers
• Maintains access to Quick Mar, EHR, payer portals and other required systems

• Communicates regularly with payor and program leadership to establish and maintain working relationships to address issues, barriers, and challenges timely and efficiently
• Negotiates length of stay with payers
• Collaborates with clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs
• Coordinates with health plan organizations, hospitals, doctors, and pharmacists to ensure services are covered and to improve treatment outcomes
• Composes and sends professional communication related to medical records and case coordination
• Monitors and provides appropriate staff updates for authorizations and length-of-stay; assists with transition for continued stays, discharges, or transfers
• Collaborates and partners with billing, clinical staff, management, UM team, and finance to ensure data accuracy, operational efficiency, timely financial collection, and adequate task coverage
• Maintains working knowledge and collaborative relationships with community partners and resources
• Promotes and models teamwork and collaboration with coworkers

• Maintains quality of care consistent with or exceeding standards set by federal, state, local, internal, and contract requirements
• Adheres to professional and ethical standards for behavioral health services
• Develops internal policies and procedures
• Guides staff in proper completion of clinical documentation to ensure accuracy and quality client care

• Maintains current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and other related industry programs and practices
• Assists with training staff to ensure operational efficiency

What you'll bring

• Master’s degree in health care, business or related field

• Licensed MHP or SUDP under WAC 388-865
• 1 year of responsible leadership experience in management or supervisory positions
• 2 years of Utilization Management experience and/or knowledge of psychiatric/behavioral health systems
• 1 year of experience as a SUDP/T and/or MHP (i.e. LPC, LMHC, LCPC, LPCC, LCMHC, LMHP, etc.)
• 3 years of experience working with individuals with behavioral health conditions

Preferably you'll bring

• Dually Credentialed as MHP and SUDP/T
• Experience working in a residential treatment facility

EEO

Pioneer human services is an equal opportunity employer of minorities/women/individuals with disabilities/protected veterans and does not unlawfully discriminate under federal, state, or local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, gender, sexual orientation, gender identity, age, physical or mental disability, or protected veteran status. EEOC is the Law/EEO Policy Statement

Pioneer Human Services is a Drug-Free Company

Pioneer Human Services is a drug free company. Pioneer’s existing drug-free workplace policy prohibits the use of marijuana, including medical marijuana, and complies with Washington law. As such, this position is subject to drug testing during employment, to include testing for marijuana