Job Information
Prime Healthcare Corporate Director of Clinical Utilization Management in Ontario, California
Overview
Prime Healthcareis 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! (https://www.primehealthcare.com/careers/benefits/)
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. 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
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.
Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes.
#LI-RK1
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 ofcompensation, 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.
Connect With Us! (https://careers-primehealthcare.icims.com/jobs/172723/corporate-director-of-clinical-utilization-management/job?mode=apply&apply=yes&in_iframe=1&hashed=-336024306)
FacilityPrime Healthcare Management Inc
LocationUS-CA-Ontario
ID2024-172723
CategoryDirector
Position TypeFull Time
ShiftDays
Job TypeExempt