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

The Director of Utilization Management will provide leadership and oversight to the utilization review and clinical appeals process. The Director of Utilization Management will oversee the respective processes and functions performed by the managers, supervisors and clerical staff in the UM department. The Director will manage coordination between the corporate Denials Management, Case management, Administration, HIM, Coding, ROI, Business Office, Financial Services and CMO for utilization Review. The Executive Director is responsible for education of physicians, nurses and related staff on documentation requirements for the Governmental claims and compliance.

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1.    Bachelor’s degree in Medicine or Nursing or related field.

2.    5 years of supervisory experience in Utilization Management.

3.    Proficiency in utilization review (InterQual-IQ or Milliman Care Guidelines-MCG)

4.    Masters in Healthcare related field

5.    CHFP/CRCR certification

Preferred qualifications:

1.    Minimum of 6  years’ experience in Utilization review /Denials management.

2.    Extensive knowledge of clinical measurement tools, and clinical outcomes; ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines; program and database development.

3.    ECFMG certification or Strong broad-based clinical knowledge and understanding of Pharmaceuticals, Pathology physiology of disease processes

4.    Excellent written and verbal communication skills. Excellent critical thinking skills.

5.    Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

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 $171,059.20 to $198,432.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.