Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 45 hospitals and has more than 300 outpatient locations in 14 states providing more than 2.6 million patient visits annually. It is one of the nation’s leading health systems with nearly 50,000 employees and physicians. Fourteen 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!
Prime Healthcare Management, Inc. 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 Off401K retirement planOutstanding MedicalDentalVision CoverageTuition ReimbursementMany more Voluntary Benefit Options!Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.
We are an Equal Opportunity Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
ResponsibilitiesThe Corporate Director of Clinical Utilization Management (UM) provides comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans, according to the EPO Plan Documents and any other applicable documents.
Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity. Assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. Provides strategic leadership, development, and supervision to utilization review department, provides interprofessional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Employee Health Plans Team, including Claims and Customer Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes.
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QualificationsRequired Qualifications:
Bachelor’s degree in Nursing, Healthcare Administration, or another relevant fieldA minimum of seven (7) years’ experience in Clinical Utilization Review or Case Management with a large Health Plan An active CA Registered Nurse licenseCurrent BCLS (AHA) certificate upon hire and maintain currentAnalytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.Knowledge of Milliman Care Guidelines, InterQual Criteria, and CMS CriteriaKnowledge of self-funded health plans, ERISA and HIPAA guidelinesExperience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)Preferred Qualifications:
Master’s Degree in Nursing, Healthcare Administration, or another relevant fieldProfessional Certification in Case ManagementClaims experience, ideally with EPO Plan.
A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $90,000.00 to $150,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire and will be dependent on a wide range of factors, including but not limited to geographic location, skill set, experience, education, credentials, and licensure. Additionally, employees in this position may be eligible to participate in the Company’s annual discretionary bonus program. Discretionary bonuses, if any, are based on a number of factors, which include but are not limited to individual and Company performance.
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