Manager, Inpatient and Post Acute Services

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $91.6k - $160.3k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

👻 Ghost score 20%

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PACIFICSOURCE

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

Not-for-profit health plans

📋 Description

• 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, 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 assess medical necessity and cost-effectiveness • Lead DSNP utilization management and integrate Medicare and Medicaid requirements • Address DSNP enrollees' needs, including social determinants of health • Ensure compliance with state and federal regulations, contractual obligations, authorizations, and appeals • Develop and update UM policies and procedures • Prepare for and manage internal and external audits • Support the UM Director with program development, implementation, and department initiatives • Supervise inpatient, post-acute, and DSNP review staff • Recruit, train, mentor, evaluate, and develop 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 requirements; perform other duties as assigned

🎯 Requirements

• 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 • Current Registered Nurse or Licensed Clinical Social Worker state license • Certified Case Manager Certification accredited by CCMC preferred • Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes, ICD-9 and ICD-10, and CPT codes • Knowledge of health insurance and State of Oregon mandated benefits • Knowledge of managed care products and third-party liability (TPL) • Ability to develop, review, and evaluate utilization and case management reports • Ability to read and comprehend written and spoken English • Clear and effective communication • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing, and lift/carry files and business materials

🏖️ Benefits

• Equal opportunity employment • Continuing education events • Professional development through training, mentoring, and performance development • Work equipment in an ergonomically configured office setting • Approximately 10% travel