Prime Healthcare

Corporate Director of Clinical Utilization Management

Facility Prime Healthcare Management Inc
Location
US-CA-Ontario
ID
2022-103933
Category
Director
Position Type
Full Time
Shift
Days
Job Type
Exempt

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 45 hospitals and has more than 300 outpatient locations in 14 states providing more than 2.6 million patient visits annually. It is one of the nation’s leading health systems with nearly 50,000 employees and physicians. Fourteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Corporate Director of Clinical Utilization Management (UM) provides comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans, according to the EPO Plan Documents and any other applicable documents. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity. The Corporate Director of Clinical UM assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. The Corporate Director provides strategic leadership, development, and supervision to utilization review department, provides interprofessional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Employee Health Plans Team, including Claims and Customer Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes.

 

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Qualifications

Required qualifications:

  1. Bachelor’s degree in Nursing, Healthcare Administration, or another relevant field
  2. A minimum of seven (7) years’ experience in Clinical Utilization Review or Case Management with a large Health Plan
  3. An active CA Registered Nurse license
  4. Current BCLS (AHA) certificate upon hire and maintain current
  5. Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.
  6. Knowledge of Milliman Care Guidelines, InterQual Criteria, and CMS Criteria
  7. Knowledge of self-funded health plans, ERISA and HIPAA guidelines
  8. Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)

Preferred qualifications:

  1. Master’s Degree in Nursing, Healthcare Administration, or another relevant field
  2. Professional Certification in Case Management
  3. Claims experience, ideally with EPO Plan.

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf

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