Manager, Inpatient and Post Acute Services

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

📋 Description

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

• Ensure that level-of-care determinations are made promptly and in accordance with clinical guidelines and regulatory standards.

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

• Track and assess 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 care transitions with post-acute providers aimed at minimizing avoidable readmissions.

• Utilize evidence-based protocols to verify medical necessity and manage cost-effectiveness in post-acute care.

• Lead utilization management for DSNP while incorporating Medicare and Medicaid requirements.

• Coordinate with care teams regarding DSNP members and address 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 related to UM and DSNP.

• Assist the UM Director with program development and departmental initiatives.

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

• Recruit, train, mentor, evaluate, and nurture the development of UM personnel.

• Create and oversee the annual department budget.

• Lead Lean process improvement initiatives using visual boards and daily huddles.

• Participate in manager/supervisor meetings and serve on strategic internal and external committees.

• Develop metrics and provide monthly/quarterly dashboards and actionable reports to senior leadership.

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

• 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 three (3) years in direct health plan experience in case management, utilization management, or disease management.

• Previous supervisory or management experience is essential.

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

• Certification as a Case Manager accredited by CCMC is preferred.

• Comprehensive understanding of medical procedures, diagnoses, care modalities, procedure codes, ICD-9 & 10, and CPT codes.

• Familiarity with health insurance and mandated benefits in the State of Oregon.

• Knowledge of managed care products and third-party liability (TPL) is required.

• Capability to develop, review, and assess utilization and case management reports.

• Proficient in reading and comprehending written and spoken English.

• Strong communication skills, both clear and effective.

• Ability to meet physical demands including stooping, bending, extended sitting/standing, repetitive typing/sorting/filing, and light lifting/carrying.

• Approximately 10% travel is required.

🏝️ Benefits

• Opportunities for continuing education events.

• Professional development options available.

• Commitment to an equal opportunity and diversity-focused workplace.