Manager, Inpatient and Post Acute Services

Equal Opportunity Statement PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values diversity and is committed to a work environment that appreciates and respects differences. Job Overview The Manager of Utilization Management (UM) for Inpatient, Post-Acute and Dual Eligible Special Needs (DSN) oversees and directs UM processes for inpatient admissions, post-acute care services, and DSNP members, ensuring compliance, quality, cost-effectiveness, and coordinated care. Essential Responsibilities Oversee daily UM operations for inpatient services, including clinical review, authorization, and concurrent review processes. Ensure timely level of care determinations aligned with clinical guidelines and regulatory requirements. Collaborate with hospital case managers, providers, and interdisciplinary teams to facilitate safe, cost‑effective discharge plans. Monitor and analyze inpatient length of stay metrics, readmissions, KPIs, and turnaround times; identify improvement areas. Oversee utilization review for skilled nursing facilities, home health, long‑term acute care, and other post‑acute settings to ensure appropriate care. Establish effective transitions of care with post‑acute providers to reduce preventable readmissions and promote optimal outcomes. Use evidence‑based protocols to ensure medical necessity for continued stays and manage cost‑effectiveness in the post‑acute phase. Provide leadership for Dual‑Eligible Special Needs Plan (DSNP) UM, ensuring integration of Medicare and Medicaid requirements. Work closely with care coordination teams to address unique DSNP needs, including social determinants of health. Ensure compliance with state and federal regulations and DSNP contractual obligations, including timely authorization and appeals processes. Develop, implement, and update UM policies and procedures. Manage internal and external audits for UM and DSNP activities. Collaborate with the UM Director to develop and implement new programs and support departmental goals. Supervise the UM inpatient team and staff focused on post‑acute and DSNP reviews. Recruit, train, mentor clinical reviewers, nurses, coordinators, and other UM personnel. Conduct performance evaluations, set goals, and foster professional development. Pursue continuing education to maintain industry best practices. Develop and monitor the annual department budget; track spending vs approved budget and take corrective action. Lead process improvement initiatives with Lean methodologies, visual boards, and daily huddles. Participate in Manager/Supervisor meetings and strategic committees. Develop and track utilization metrics; present dashboards and reports to senior leadership. Supporting Responsibilities Serve as backup to the Director of Utilization Management as needed. Meet department and company performance and attendance expectations. Follow PacificSource privacy policy and HIPAA laws concerning confidentiality and security of protected health information. Perform other duties as assigned. Success Profile Minimum of seven (7) years clinical experience and at least 3 years 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 (CCMC) certification preferred. Knowledge Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes (ICD‑9 &10, CPT), health insurance, and 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. Preference for health insurance and state‑mandated benefits experience in adult education. Competencies Building Trust Building a Successful Team Aligning Performance for Success Building Partnerships Customer Focus Continuous Improvement Decision Making Facilitating Change Leveraging Diversity Driving for Results Environment Work in a general office setting with ergonomically configured equipment. Travel required approximately 10% of the time. Skills Accountable leadership Collaboration Data‑driven & analytical Delegation Effective communication Listening (active) Situational leadership Strategic thinking Compensation Compensation Disclaimer: The wage range reflects the full range for this position. The maximum amount listed represents the highest possible salary; actual compensation will be determined by qualifications, experience, education, and internal equity. Base Range: $91,587.15–$160,277.52. Values Core values: commitment to doing the right thing; teamwork; customer service responsibility; open communication; community improvement; social justice; equity, diversity, and inclusion; creativity; innovation; pursuit of excellence. Physical Requirements Stoop and bend. Sit and/or stand for extended periods while performing core functions. Repetitive motions such as typing, sorting, filing. Light lifting and carrying of files and business materials. Ability to read and comprehend written and spoken English. Communicate clearly and effectively. Disclaimer This job description indicates the general nature and level of work performed by employees in this position and is subject to change. It is not designed to be a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains at‑will at all times. #J-18808-Ljbffr PacificSource