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! 

VP Utilization Review and Clinical Denials Management will provide strategic leadership, direction and operational management for the Utilization Review and Clinical Denial Management teams. This position encompasses process oversight for all lines of business including managed care, commercial and government programs across all Prime Healthcare facilities. The VP will lead a dedicated team to implement best practices and drive strategies to manage the clinical denials and ensure efficient revenue cycle management processes.

The VP will collaborate with all revenue cycle stakeholders including Chief Medical Officers, Clinical teams, Admitting and all stake holders from the Revenue cycle team to collaborate on Utilization review, denial management protocols, and Business Intelligence/Analytics along with maintaining the Regulatory & Compliance standards for UM operations. This role will focus on fostering a collaborative work environment to successfully achieve outcomes relative to improved experience of care and appropriate resource utilization. The VP will optimize care coordination across the continuum to reduce readmissions and improve patient outcomes. The VP will coordinate effectively with Corporate leadership, hospital C-suite and Clinical departments including Clinical Documentation Improvement, Medical Review and Appeals, Business Office and Clinical leaders to execute a strategic vision for the UM department while aligning with the organization’s goals.

The VP is accountable for strategic and operational excellence of the Utilization Review team within Clinical Services including administrative and care cost initiatives, system development and delivery of high-quality outcomes, compliance with all State and Federal regulations that affect Utilization Review and Clinical Denial management activities along with executive level reporting and communication.

#LI-DNI

Required qualifications:

1. Master’s in healthcare or related field is required

2. Medical Doctor or Graduate of an accredited school of nursing and currently licensed as a Registered Nurse required.

3. Minimum of 10 years of experience in healthcare.

4. Must have analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.

5. Excellent communications skills

Preferred qualifications:

1. Milliman and InterQual review expertise.

2. Minimum 7 years in a leadership position over multiple hospitals or a health system.

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.  Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.  A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $170,560.00 to $257,004.80 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. 

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