Utilization Review Clinician

Avalon Health Care Management is now hiring a Case Manager of Utilization Management and Authorizations to join our team!

Avalon Health Care Management is hiring an experienced Case Manager to join our team. This role is critical to supporting our Skilled Nursing Facility (SNF) operations by managing authorizations, utilization management, concurrent review, and payor coordination while ensuring smooth transitions of care.

The Case Manager serves as a key liaison between physicians, interdisciplinary care teams (IDT), payors, and discharge planners. This position ensures timely communication of patient progress, and determination of medical necessity while supporting optimal outcomes and revenue integrity.

Full-time are eligible for:

• 401K
• Medical, Dental & Vision
• FSA & Dependent Care FSA
• Life Insurance
• AD&D, Long Term Disability, Short Term Disability
• Critical Illness, Accident, Hospital Indemnity
• Legal Benefits, Identity Theft Protection
• Pet Insurance and Auto/Home Insurance.

Responsibilities:

• Serve as a critical part of the pre-admission process, including:
  • Pre-admission Payor authorizations
  • Insurance verification
  • Single Case Agreements (SCA's)/Letters of Agreement(LOA's)
• Perform Utilization Management (UM) activities, including level-of-care determination
• Conduct concurrent reviews, obtaining accurate and timely clinical information from physicians, therapy, and IDT and communicating updates to payors as directed
• Negotiate appropriate levels of care within contract terms with payor case managers
• Utilize SCA/LOA for non-contracted payor arrangements
• Act as a liaison between payors and internal decision-makers to ensure clear, accurate, and timely exchange of information
• Coordinate and communicate patient progress, expected discharge plans, and transitions to the next level of care
• Provide complete, accurate, and timely case management documentation and reports to payors, IDT, and billing staff
• Monitor records requested by insurance providers to ensure completeness and compliance

Care Coordination & Business Development

• Network through professional case management organizations and attend community meetings regularly
• Maintain a primary focus on census development and revenue enhancement

Qualifications:

• Associate degree in a health or human services field preferred
• Certified Case Manager (CCM) credential issued by the Commission for Case Manager Certification (CCMC) preferred
• Minimum two (2) years of medical or utilization management case management experience preferred
• Comprehensive knowledge and prior experience working with:
  • Health Plans
  • Managed Care Organizations (MCOs)
  • Third Party Administrators (TPAs)
  • Medicare Advantage and HMO plans
  • Risk-bearing entities including:
    • Medical Groups
    • Independent Physician Associations (IPAs)
    • Hospital-owned health plans (e.g., Kaiser, Select Health)
• Ability to negotiate rates and provide complete, timely case management reports
• Familiarity with long-term care and/or sub-acute care strongly preferred
• Nursing background strongly preferred for level-of-care determination
• Strong oral and written communication skills required

If you are a highly motivated Case Manager with strong payor-side experience and a passion for supporting quality patient care while navigating complex authorization and utilization processes, we encourage you to apply and join the team at Avalon Health Care.