Clinical Manager, Utilization Management, Full-Time, Days (**For internal candidate only)

Reports to the UM Clinical Director. The UM Manager is responsible for assisting with the overall operations and direction of the Utilization Management department. The UM Manager is responsible for incorporating best practices and ensures effective utilization reviews that will guarantee appropriate reimbursement for hospital services and manages and ensures the productivity of the department in completing initial reviews and concurrent reviews to ensure that the patient is getting the right care in a timely, safe, efficient, and cost‑effective way. Additionally, the UM manager must monitor retrospective reviews after treatment has been completed or after discharge to ensure appropriate reimbursement. Works collaboratively with Care Management leadership in providing feedback about any opportunities, trends, and gaps regarding avoidable days or delays or develops a plan when a patient is no longer meeting the acute level of care. Additionally, the UM Manager works closely with physicians and other providers including the Physician Advisor to develop improved utilization of effective and appropriate services. The UM Manager will provide after‑hour support for the Access Department and serve as a point of contact for conflict resolution and provide administrative support for both UM Department and Access Department. Required Skills Must have working knowledge of Access Department, utilization review, and inpatient care management procedures in an acute care setting. Results‑oriented professional management with customer service skills including proven time‑management, organizational, and prioritization skills. Must possess excellent verbal and written communication skills and thorough knowledge of processes and details integral to utilization review and clinical documentation improvement. Must have experience in planning and effectively managing departmental budgets and other fiscal responsibilities. Must be able to demonstrate ability and skill through prior experience and/or academic expertise in actively leading and managing any large‑scale change. Must have expertise in data management and analysis related to length of stay, case mix, resource utilization, etc. with the intent of identifying opportunities for improvement as well as validating current performance. Must have current knowledge of federal and health plan audit programs such as CMS RAC and other related audit activities, value‑based purchasing programs, readmission and other related oversight programs resulting in denied reimbursements. Must have the ability to perform cost‑benefit and detailed strategic analysis on data and information sets and develop reports accordingly. Must have working knowledge of computer applications such as Excel, Word, and PowerPoint. Required Experience Required Active California RN License. Bachelor's degree in nursing. Minimum of two (2) years’ experience in case management, social work, utilization review, and discharge planning in an acute care hospital. Minimum of two (2) years leadership and department management experience. Preferred Master’s in Health Administration or related business field preferred. Case Manager Certification (CCM) or (Accredited Case Manager (ACM) preferred. Address 11500 Brookshire Ave. Salary 54.32-89.63 Shift Days Zip Code 90241 #J-18808-Ljbffr PIH Health