Corporate Director of Clinical Utilization Management

Prime Healthcare; Ontario; On-site; USD 90,000 - 150,000; Full time

Job summary

Join a forward-thinking health system as a Corporate Director of Clinical Utilization Management. In this pivotal role, you will oversee the Utilization Review process for Employee Health Plans, ensuring quality improvement initiatives that promote positive member outcomes. You'll provide strategic leadership and collaborate with case managers and the Employee Health Plans Team to guide complex authorizations and appeals. This position offers a competitive compensation package, including a comprehensive benefits plan that allows for individual customization. If you are passionate about healthcare and ready to make a significant impact, this opportunity is for you.

Benefits

Paid Time Off

401K retirement plan

Outstanding Medical Coverage

Dental Coverage

Vision Coverage

Tuition Reimbursement

Voluntary Benefit Options

Qualifications

• 7+ years in Clinical Utilization Review or Case Management with a large Health Plan.
• Active CA Registered Nurse license required.

Responsibilities

• Oversee the Utilization Review process for Employee Health Plans.
• Provide strategic leadership and supervision to the utilization review department.

Skills

Analytical ability

Problem identification

Data assessment and evaluation

Education

Bachelor’s degree in Nursing

Bachelor’s degree in Healthcare Administration

Master’s Degree in Nursing

Master’s Degree in Healthcare Administration

Tools

Microsoft Word

Microsoft Excel

Job description

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!

Prime Healthcare Management, Inc. 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
• 401K retirement plan
• Outstanding Medical
• Dental
• Vision Coverage
• Tuition Reimbursement
• Many more Voluntary Benefit Options!

Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.

We are an Equal Opportunity 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.

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.
• 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.

Qualifications

Required Qualifications:

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

Preferred Qualifications:

• Master’s Degree in Nursing, Healthcare Administration, or another relevant field
• Professional Certification in Case Management
• 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.