The Manager of Utilization Management (UM) for Inpatient, Post-Acute and Dual Eligible Special Needs (DSN oversees and directs the utilization management process for inpatient admissions, post-acute care services, and DSNP members). This role ensures compliance with regulatory requirements, optimizes quality and cost-effectiveness, and facilitates coordinated care across the care continuum. The Manager works closely with interdisciplinary teams to achieve organizational goals and high standards of member-centric care and is integrally involved in the Health Services (HS) program development, implementation, and strategic planning.

Essential Responsibilities:

Oversee daily UM operations for inpatient services including clinical review, authorization, and concurrent review processes to ensure efficient and effective utilization management.
Ensure timely level of care determinations alignment with clinical guidelines and regulatory requirements to ensure patients receive the right care at the right time.
Collaborate with hospital case managers, providers, and interdisciplinary teams to facilitate safe and cost-effective discharge plans for patients.
Monitor and track and analyze inpatient length of stay metrics, readmissions, key performance indicators (KPIs), and turnaround times to identify areas for improvement.
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 member outcomes.
Use evidence-based protocols to ensure medical necessity for continued stays and manage cost-effectiveness in the post-acute phase.
Provide leadership and direction for Dual-Eligible Special Needs Plan (DSNP) utilization management, ensuring integration of Medicare and Medicaid requirements.
Work closely with care coordination teams to address the unique needs of DSNP enrollees, 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 regularly update policies and procedures to ensure compliance and best practices in utilization management.
Prepare for and manage internal and external audits pertaining to UM and DSNP activities to ensure compliance and readiness.
Work closely with the UM Director to facilitate the development and implementation of new programs and support ongoing success of department goals and initiatives.
Directly supervise the UM inpatient team, along with staff focused on post-acute and DSNP reviews, ensuring effective team performance.
Recruit, train, and mentor clinical reviewers, nurses, coordinators, and other UM personnel to build a skilled and knowledgeable team.
Conduct performance evaluations, set goals, and foster professional development to maintain a high-performing team.
Attend continuing education events: Attend continuing education events to ensure that PacificSource UM programs maintain current industry best practices.
Develop and monitor the annual department budget: Develop the annual department budget, monitor spending versus the approved budget throughout the year, and take corrective action where needed.
Responsible for process improvement and collaboration with other departments to improve interdepartmental processes using Lean methodologies, visual boards, and daily huddles to monitor KPIs and identify improvement opportunities.
Actively participate as a key team member in Manager/Supervisor meetings to discuss and address departmental and organizational issues.
Actively participate in various strategic internal and external committees to disseminate information and represent company philosophy.
Develop and track metrics to evaluate utilization trends, authorization outcomes, readmission rates, and other key performance indicators, presenting monthly/quarterly dashboards and reports to senior leadership with actionable insights for continuous improvement.

Supporting Responsibilities:

Serve as back up to the Director of Utilization Management, as needed
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of seven (7) years of clinical experience required and a minimum of 3 years direct health plan experience in case management, utilization management, or disease management. Prior supervisory or management experience required.

Education, Certificates, Licenses: Registered Nurse or Licensed Clinical Social Worker with current appropriate state licenses. Certified Case Manager Certification as accredited by CCMC preferred.

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes, including ICD-9 & 10, CPT codes, health insurance and State of Oregon mandated benefits. Knowledge of managed care products and third-party liability (TPL) is required. Ability to develop, review and evaluate utilization and case management reports. Knowledge of health insurance and State mandated benefits experience in adult education preferred.

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 inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:
Accountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:
$91,587.15 - $160,277.52

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

PacificSource

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