Manager, Inpatient and Post Acute Services

Job not on LinkedIn

🔥 0 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – 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 and analyze 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 to confirm medical necessity and manage post-acute cost-effectiveness • Lead DSNP utilization management while integrating Medicare and Medicaid requirements • Coordinate with care teams regarding DSNP members and 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 UM and DSNP audits • Support the UM Director with program development and department initiatives • Directly supervise inpatient, post-acute, and DSNP review staff • Recruit, train, mentor, evaluate, and develop UM personnel • Develop and monitor the annual department budget • Lead Lean process improvement using 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 • 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 • 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 & 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 • Ability to communicate clearly and effectively • Ability to perform physical requirements including stooping, bending, extended sitting/standing, repetitive typing/sorting/filing, and light lifting/carrying • Approximately 10% travel required

🏖️ Benefits

• Continuing education events • Professional development opportunities • Equal opportunity and diversity-focused work environment