Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!
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The position of Senior Utilization Review Manager is responsible for the oversight of third-party payer utilization review (UR), denial management (DM) processes in addition to the additional special projects. Working with the UR Manager/Supervisor(s), a Senior manager functions as a subject matter expert (SME) for the UR Process and takes an active role in managing the process and coordinating with Corporate Utilization Review and Clinical appeals team, thereby managing daily operations within the department. Provides supervision and direction for UR/ Clinical Appeals process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitates peer to-peer communication and authorization appeals process following utilization review submission to respective insurances. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Demonstrates appropriate knowledge of payer contract changes as they pertain to level of care determination and the appeal/denial process. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration / CMO and the Utilization Review Committee wherever applicable. Participates in various Utilization committee meetings with stakeholders from all departments and corporate leadership team to provide necessary education and discuss progress and protocols for Insurance authorization and denial prevention strategies. In tandem with the Training Supervisor keeps abreast with the ongoing education/training to stay current with emerging industry trends on utilization review and denials management. Performs ongoing audits, to monitor UR and appeal/denial process and develops process improvement plans for identified deficiencies so as to create opportunities for staff development and to optimize performance outcome. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.
EDUCATION, EXPERIENCE, TRAINING
Required qualifications:
1. Medical Graduate, Dental Graduate or Nursing Graduate or related healthcare required professional.
2. Bachelor’s with 3 years of relevant UR experience OR Masters with 1+ Years of relevant Utilization review/ Denial management experience.
Preferred qualifications:
1. ECFMG Certification And/or Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
2. Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes; ability to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines; program and database development a plus
3. 1+ year of clinical experience in acute care setting preferred.
4. Excellent written and verbal communication skills. Excellent critical thinking skills.
5. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $110,968.00 to $173,035.20 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
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