Manager Utilization Management - CommonSpirit Health

Dignity Health one of the nation’s largest health care systems is a 22-state network of more than 9000 physicians 63000 employees and 400 care centers including hospitals urgent and occupational care imaging and surgery centers home health and primary care clinics. Headquartered in San Francisco Dignity Health is dedicated to providing compassionate high-quality and affordable patient-centered care with special attention to the poor and underserved. For more information please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.

The Utilization Management (UM) Manager is responsible for managing day-to-day UM operations within the markets, focusing on effective team management, authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. Act as a working manager within Utilization Management, performing essential duties and responsibilities (utilization reviews, denials, and authorizations) in non-represented markets, with a time allocation of no more than 40% of the total work hours. Ensure a balance between management and operational responsibilities to maintain effective team leadership and oversight. This role supports the UM Director in ensuring efficient operations with all processes, policies, strategies and ensuring compliance with all regulatory and payer requirements.

We offer the following benefits to support you and your family:

• Health/Dental/Vision Insurance
• Flexible spending accounts
• Voluntary Protection: Group Accident, Critical Illness and Identity Theft
• Adoption Assistance
• Free Premium Membership to Care.com with preloaded credits for children and/or dependent adults
• Employee Assistance Program (EAP) for you and your family
• Paid Time Off (PTO) Tuition Assistance for career growth and development
• Retirement Programs
• Wellness Programs 

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Minimum:

• Bachelor's degree in Nursing, Health Care Administration or related clinical field
• Minimum 5 years of clinical case management (Utilization Management, Denial Management, Care Coordination)
• Minimum 3 years management experience in a clinical case management department.(Utilization Management,Denial Management,Care Coordination)
• Current California RN license
• National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within 2 years upon hire.

Qualified candidates will have the following knowledge and skills:

• Comprehensive knowledge of utilization management
• Medicare, Medicaid, and commercial admission and review requirements
• In-depth knowledge of utilization management processes and best practices
• Strong managerial and decision-making skills
• Excellent communication skills and the ability to work collaboratively.
• Proficient in healthcare IT systems relevant to utilization management
• Effective leadership and team-building skills
• Excellent organizational and communication skills
• Ability to work unde rpressure and manage multiple priorities
• Knowledge of CMS standards and requirements
• Ability to work as a team player and assist other members of the team where needed.

We prefer candidates with:

• Master's degree in Nursing,Health Care Administration or related clinical field.
• Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services