Manager, Inpatient and Post Acute Services

Job not on LinkedIn

🔥 0 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $91.6k - $160.3k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

👻 Ghost score 0%

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 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 times • 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 for medical necessity and cost-effectiveness • Lead DSNP utilization management and integrate Medicare and Medicaid requirements • Address DSNP enrollee needs, including social determinants of health • Ensure compliance with state and federal regulations, contractual obligations, authorizations, and appeals • Develop and update utilization management policies and procedures • Prepare for and manage internal and external audits • Support the UM Director with new programs and department initiatives • Directly supervise inpatient, post-acute, and DSNP review staff • Recruit, train, mentor, evaluate, and develop UM personnel • Attend continuing education events • 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 committees • Develop and track utilization metrics and present monthly/quarterly dashboards and reports to senior leadership • Serve as backup to the Director of Utilization Management • Meet performance and attendance expectations • Follow privacy policy and HIPAA requirements • Perform other duties as assigned

🎯 Requirements

• Minimum of seven (7) years of clinical experience required • Minimum of 3 years of direct health plan experience in case management, utilization management, or disease management • Prior supervisory or management experience required • 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, ICD-9 and ICD-10, and CPT codes • Knowledge of health insurance and State of Oregon mandated benefits required • 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 and filing, and light lifting and carrying

🏖️ Benefits

• Equal opportunity employment • Continuing education opportunities • Professional development through training and mentoring • Work inside in a general office setting with ergonomically configured equipment • Participation in strategic internal and external committees • Employee values include open communication, community improvement, and social justice, equity, diversity and inclusion • At-will employment