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.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3.7 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 35 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology.For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

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
Minim 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
Variable

FLSA Status
Professional-Exempt

Zip Code
90241

PIH Health Downey Hospital

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Clinical Manager, Utilization Management, Full time, Evenings