Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen 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!

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf

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.
• Assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs.
• 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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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.

A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $90,000.00 to $150,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire and will be dependent on a wide range of factors, including but not limited to geographic location, skill set, experience, education, credentials, and licensure. Additionally, employees in this position may be eligible to participate in the Company’s annual discretionary bonus program. Discretionary bonuses, if any, are based on a number of factors, which include but are not limited to individual and Company performance.