Utilization Manager

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 a Utilization Manager with 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.

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.

New hires for this position typically start between $80,168.40 and $80,770.90 Spokane Region, $80,168.40 and $88,650.99 North Sound Region, $80,168.40 and 97,931.73 Seattle Region 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.

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.

• Provides leadership, guidance, training, and communication to assigned staff
• Analyzes data to identify 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
• Collaborates with clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs
• Coordinates with health plan organizations, hospitals, doctors, and…