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Clinical Utilization Management Director

2 months ago

Ontario, California, United States Prime Healthcare Management Inc Full time
Job Summary

Prime Healthcare Management, Inc. is seeking a highly skilled Clinical Utilization Management Director to join our corporate team. As a key member of our healthcare operations team, you will be responsible for providing comprehensive oversight of the Utilization Review process for our self-insured Employee Health Plans.

The ideal candidate will have a strong background in clinical utilization review, case management, and healthcare operations. You will be responsible for integrating and coordinating services to promote positive member outcomes, frequent executive-level reporting, and tracking department and individual team productivity.

This is a challenging and rewarding role that requires strong analytical and problem-solving skills, as well as excellent communication and leadership abilities. If you are a motivated and results-driven professional with a passion for healthcare operations, we encourage you to apply.

Responsibilities

The Clinical Utilization Management Director will be responsible for:

  • Providing comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans
  • Integrating and coordinating services to promote positive member outcomes
  • Frequent executive-level reporting and tracking department and individual team productivity
  • Assessing needs, planning, communicating, designing services and strategies to forward the mission and serve member needs
  • Providing strategic leadership, development, and supervision to the utilization review department
  • Collaborating with facility-based case managers and discharge planners to provide guidance on complex Authorizations, Referrals, Denials, and Appeals
Qualifications

The ideal candidate will have:

  • A 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
  • Excellent analytical and problem-solving skills
  • Strong communication and leadership abilities

Preferred qualifications include a Master's degree in Nursing, Healthcare Administration, or another relevant field, professional certification in Case Management, and claims experience with EPO Plans.

A competitive compensation package is offered, including a salary range of $90,000.00 to $150,000.00 on an annualized basis, plus eligibility for the Company's annual discretionary bonus program.