Manager, Inpatient and Post Acute Services

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🕒 Agosto 25

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $91.587 - $160.277 / ano

⏰ Tempo Integral

🟠 Sênior

🔴 Especialista

👔 Gerente

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PacificSource Health Plans

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 1933

🏥 Saúde

🛡️ Seguros

⚕️ Seguro de Saúde

Healthcare • Insurance • Healthcare Insurance

A PacificSource Health Plans é uma provedora de saúde que oferece uma gama de soluções de seguros de saúde, incluindo planos para indivíduos, famílias e empregadores. Suas ofertas incluem planos para Medicare e Medicaid, cobertura odontológica e serviços administrativos para grupos pequenos e grandes. Comprometida com o cuidado dos membros, a PacificSource enfatiza o atendimento ao cliente e fornece vários recursos para a gestão da saúde, incluindo suporte à saúde mental e programas de bem-estar.

Descrição

• Oversee daily utilization management operations for inpatient services, including clinical review, authorization, and concurrent review • Ensure timely level-of-care determinations align with clinical guidelines and regulatory requirements • Collaborate with hospital case managers, providers, and interdisciplinary teams on safe, cost-effective discharge plans • Monitor inpatient length of stay, readmissions, KPIs, and turnaround-time metrics • Oversee utilization review for skilled nursing facilities, home health, long-term acute care, and other post-acute settings • Establish transitions of care with post-acute providers to reduce preventable readmissions • Apply evidence-based protocols to determine medical necessity and manage post-acute cost-effectiveness • Lead DSNP utilization management and integrate Medicare and Medicaid requirements • Coordinate with care teams to address DSNP enrollees’ needs and social determinants of health • Ensure compliance with regulations, contractual obligations, authorization, and appeals processes • Develop and update utilization management policies and procedures • Prepare for and manage internal and external UM and DSNP audits • Support the UM Director with new programs, strategic planning, and department initiatives • Supervise inpatient, post-acute, and DSNP review teams • Recruit, train, mentor, and evaluate clinical reviewers, nurses, coordinators, and other UM personnel • Develop and monitor the annual department budget • Lead process improvement using Lean methodologies, visual boards, and daily huddles • Participate in manager/supervisor meetings and strategic internal and external committees • Develop metrics and present monthly/quarterly dashboards and actionable reports to senior leadership • Serve as backup to the Director of Utilization Management as needed • Follow privacy policy and HIPAA confidentiality and security requirements • Meet performance and attendance expectations and perform other assigned duties

🎯 Requisitos

• Minimum of seven (7) years of clinical experience • Minimum of 3 years of direct health plan experience in case management, utilization management, or disease management • Prior supervisory or management experience • Registered Nurse or Licensed Clinical Social Worker with current appropriate state licenses • Certified Case Manager Certification accredited by CCMC preferred • Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes, including ICD-9 & 10 and CPT codes • Knowledge of health insurance and State of Oregon mandated benefits • Knowledge of managed care products and third-party liability (TPL) required • Ability to develop, review, and evaluate utilization and case management reports • Experience with adult education preferred • Ability to read and comprehend written and spoken English • Ability to communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and light lifting/carrying

🏖️ Benefícios

• Equal opportunity employment • Continuing education events • Professional development opportunities • Travel opportunities (approximately 10% of the time)