Manager, Inpatient and Post Acute Services

This is a fully remote position, open to applicants in Florida.

📋 Description

• Manage daily operations of utilization management for inpatient services, encompassing clinical review, authorization, and concurrent review.

• Ensure that timely level-of-care decisions are in accordance with clinical guidelines and regulatory standards.

• Collaborate with hospital case managers, providers, and interdisciplinary teams to develop safe and cost-effective discharge plans.

• Monitor metrics such as inpatient length of stay, readmissions, key performance indicators (KPIs), and turnaround times.

• Supervise utilization review processes for skilled nursing facilities, home health, long-term acute care, and other post-acute environments.

• Establish transitions of care with post-acute providers to minimize preventable readmissions.

• Implement evidence-based protocols concerning medical necessity and cost-effectiveness.

• Lead the DSNP utilization management and ensure integration of Medicare and Medicaid requirements.

• Address the needs of DSNP enrollees, including considerations of social determinants of health.

• Ensure adherence to state and federal regulations, contractual obligations, authorizations, and appeals processes.

• Develop and revise utilization management policies and procedures as needed.

• Prepare for and oversee both internal and external audits.

• Support the UM Director in the development of new programs and departmental initiatives.

• Directly supervise staff involved in inpatient, post-acute, and DSNP reviews.

• Recruit, train, mentor, assess, and develop personnel within the UM department.

• Attend professional development and continuing education events.

• Create and manage the annual departmental budget.

• Lead process improvement initiatives utilizing Lean methodologies, visual boards, and daily huddles.

• Participate in managerial meetings and strategic committees.

• Develop and monitor utilization metrics, providing monthly and quarterly dashboards and reports to senior leadership.

• Act as a backup for the Director of Utilization Management.

• Meet performance and attendance standards.

• Adhere to privacy policies and HIPAA regulations.

• Perform additional duties as assigned.

⛳️ Requirements

• At least seven (7) years of clinical experience required.

• A minimum of 3 years of direct health plan experience in case management, utilization management, or disease management.

• Prior experience in a supervisory or managerial role is required.

• Must be a Registered Nurse or Licensed Clinical Social Worker with current appropriate state licenses.

• Certified Case Manager Certification accredited by CCMC is preferred.

• Comprehensive knowledge of medical procedures, diagnoses, care modalities, procedure codes, ICD-9 and ICD-10, as well as CPT codes.

• Understanding of health insurance and State of Oregon mandated benefits is required.

• Familiarity with managed care products and third-party liability (TPL) is essential.

• Ability to develop, assess, and evaluate utilization and case management reports.

• Experience in adult education is preferred.

• Capability to read and comprehend written and spoken English proficiently.

• Excellent communication skills, both clear and effective.

• Ability to stoop and bend, sit and/or stand for prolonged periods, perform repetitive tasks such as typing, sorting, and filing, as well as light lifting and carrying.

🏝️ Benefits

• Equal opportunity employment.

• Opportunities for continuing education.

• Professional development through training and mentoring.

• Work in an office environment with ergonomically designed equipment.

• Participation in strategic internal and external committees.

• Employee values emphasize open communication, community improvement, and principles of social justice, equity, diversity, and inclusion.

• At-will employment.